LIBRARY OF CONGRESS. 

ITS ^H 
@ijap + Sujujrigljt Ifu- 

Shelf JtfiLSL 



UNITED STATES OF AMERICA. 



MINOR SURGERY 



BANDAGING 



INCLUDING THE 



TREATMENT OF FRACTURES AND DISLOCATIONS, 

TRACHEOTOMY, INTUBATION OF THE LARYNX, 

LIGATIONS OF ARTERIES AND 

AMPUTATIONS. 



BY 



HENRY R. WHARTON, M.D., 

'i 

DEMONSTRATOR OF SURGERY AND LECTURER ON SURGICAL DISEASES OF CHILDREN IN THI 

UNIVERSITY OF PENNSYLVANIA , SURGEON TO THE PRESBYTERIAN HOSPITAL, THE 

METHODIST EPISCOPAL HOSPITAL, THE CHILDREN'S HOSPITAL, AND THE 

DREXEL HOSPITAL FOR CHILDREN J CONSULTING SURGEON 

TO THE RUSH HOSPITAL FOR DISEASES OF 

THE CHEST, ETC. 



WITH FOUR HUNDRED AND THREE ILLUSTRATIONS. 




PHILADELPHIA: 

LEA BROTHERS & CO. 

1891. 






Entered according to the Act of Congress, in the year 1891, by 

LEA BEOTHEES & CO., 
in the office of the Librarian of Congress. All rights reserved. 



DOKNAN, PKIJSTKK. 



PREFACE 



The author has, in this work, endeavored to present, 
in as concise a manner as possible, a description of the 
various bandages, surgical dressings, and minor surgical 
procedures which are employed in the practice of surgery 
at the present time. The preparation and application of 
the antiseptic dressings now most commonly used have 
also received full consideration. The article upon Ban- 
daging is fully illustrated with cuts, mostly new and 
taken from photographs, which, it is hoped, will prove of 
value as furnishing an accurate representation of the 
most important bandages used in surgical practice ; the 
same is in a measure true of the article upon the dressing 
of Fractures and Dislocations, in which many new cuts 
of the same kind appear. 

The work also contains short articles upon Trache- 
otomy, Intubation of the Larynx, Ligations of Arteries, 
and Amputations, and, although these procedures are 
scarcely to be included with those of Minor Surgery, it 
is hoped that their description will increase the value 
of the work to medical students, for whose use it has 



IV PREFACE. 

been prepared. The author's thanks are due to Dr. 
Walter D. Green for his kind assistance in revising the 
proof-sheets, and to Mr. James Wood for the skilful 
photographic work used in illustrating several of the 
articles. 

112 South Eighteenth St., 

Pbiladelpiua, August, 1891. 



CONTEXTS 



PART I. 

BANDAGING. 

Varieties of Bandages 
Bandages of the Head and Neck 
Bandages of the Upper Extremity 
Bandages of the Trunk . . ... 
Bandages of the Lower Extremity 
Special Bandages .... 
Fixed Dressings or Hardening Bandages 



PAGE 

13-32 
32-44 
44-58 
58-64 
65-76 
76-82 
82-98 



PART II. 
MINOR SURGERY. 

Theory of Asepsis and Antisepsis in Wound 

Treatment 99-101 

Methods and Dressings Employed in Wounds to 

Secure Asepsis 101-109 

Preparation of Materials and Dressings Used in 

Aseptic Surgery 109-120 

Preparations for and Details of Aseptic Opera- 
tions 120-129 

Materials Used in Surgical Dressings . . 129-135 

Procedures Employed in Minor Surgery . . 135-192 

Anaesthetics 192-201 

Trusses 201-206 

Use of Catheters and Bougies .... 206-216 

Sutures and Ligatures ...... 217-235 



VI CONTENTS. 

PAGE 

Ligatures Employed in the Treatment of Vas- 
cular Growths 235-240 

Treatment of Hemorrhage . ... 241-262 

Treatment of Abscesses 263-266 

Dressing of Wounds, Burns and Scalds, Bedsores, 

Sprains 266-275 

Tracheotomy, Laryngotomy, and Laryngo-trache- 

otomy ... 275-286 

Intubation of the Larynx 286-289 

PART III. 

FRACTURES . . . 290-302 

Treatment of Special Fractures .... 302-361 

PART IV. 

DISLOCATIONS , . . 361-364 

Treatment of Special Dislocations . . . 364-392 

PART V. 

LIGATION OF ARTERIES . . 393-395 

Ligation of Special Arteries . . . . 395-427 

PART VI. 

AMPUTATIONS . . . 428 

Special Amputations . . 428-4S0 

Index 483 



PAET I. 

BANDAGING 



Bandages constitute one of the most widely used and 
important surgical dressings ; they are employed to hold 
dressings in contact with the surface of the body, to make 
pressure, to hold splints in place in the treatment of frac- 
tures and dislocations, and to restore to their natural posi- 
tion parts which may have become displaced. 

Bandages may be prepared of various materials, such as 
linen, crinoline, flannel, cheese or tobacco cloth, rubber 
sheeting, or muslin, bleached or unbleached ; the latter ma- 
terial is the most commonly employed, by reason of the ease 
with which it is obtained and its cheapness ; flannel, from 
its elasticity, is sometimes used, but its employment for 
bandages is now generally limited to its use in dressings for 
operative work in connection with the eye, and for a primary 
roller in the application of the plaster- of-Paris dressings. 

Bandages are either simple, when composed of one piece 
of material such as the ordinary roller bandage, or compound 
when prepared of one or more pieces, adapted by size and 
shape to peculiar objects. 

Bandages are also described as uniting, dividing, com- 
pressing, expelling or retaining bandages, according to the 
purposes they serve by their application. 

The importance of being perfectly familiar with the gen- 
eral rules of bandaging and proficient in the application of 
the roller bandage cannot be over-estimated, and both the 
student and general practitioner will never have cause to 

2 



14 BANDAGING. 

regret the time occupied in learning to apply neatly this 
form of surgical dressing. 

A well-applied bandage adds to the comfort of the patient, 
and the method of its application often secu-res for the phy- 
sician the confidence both of the patient and of his friends, 
while, on the other hand, a badly applied bandage is apt to 
be uncomfortable and insecure, and to meet with their ad- 
verse criticism. 

The Roller Bandage. 

The roller bandage consists of a strip of woven material, 
prepared from some of the materials previously mentioned, 
of variable length and width according to the portion of the 
body to which it is to be applied ; this, for ease of applica- 
tion, is rolled into a cylindrical form. 

The material commonly employed for the roller bandage 
is unbleached muslin, although, for special purposes, linen, 

Fig 1. 




Bandage winder. 

flannel, rubber sheeting, crinoline or cheese-cloth may be 
used. It is important that the roller bandage should consist 
of one piece, free from seams and selvage, for if made of a 
number of pieces sewed together, or if it contains creases or 



THE ROLLER BANDAGE. 15 

selvage it cannot be so neatly applied, and it is not so com- 
fortable to the patient, as it is apt to leave creases upon the 
skin. 

In preparing the ordinary muslin bandage the material is 
torn in strips varying in length and width according to the 
part of the body to which it is to be applied, and it is then 
rolled into a cylinder, either by the hand or by a machine 
constructed for the purpose. (Fig. 1.) 

It is important that every student and practitioner should 
be able to roll a bandage by hand, for in practice the medical 

Fig. 2. 




Rolling a bandage by band. 

attendant may at any moment be called upon to roll a ban- 
dage, in order to apply a dressing, and as the art of preparing 
a bandage is acquired by a little practice, it should be famil- 
iar to. every student and physician. To roll a bandage by 
hand the strip should be folded at one extremity several 
times until a small cylinder is formed ; this is then grasped 
by its extremities by the thumb and index finger of the left 
hand ; the free extremity of the strip is then grasped between 
the thumb and index finger of the right hand, and by alter- 
nate pronation and supination of the right hand the cylinder 
is revolved and the roller is formed ; the firmness of the 



16 



BANDAGING. 



roller will depend upon the amount of tension which is kept 
upon the free extremity of the strip during the revolution of 
the cylinder. (Fig. 2.) 



Fig. 3. 




Single roller. 



A bandage rolled in the form of a cylinder is called a 
single or single-headed roller (Fig. 3); if rolled from each 



Fig. 4. 




Double roller. 



extremity toward the centre so that two cylinders are formed 
joined by the central portion of the strip, the double or 



GENERAL RULES FOR BANDAGING. 17 

double- headed roller is formed. (Fig. 4.) Double rollers 
are not much used, and in practice the single roller will be 
found to be amply sufficient for the application of almost all 
the bandages employed in surgical dressings. 

The free end of the roller bandage is called the initial 
extremity ; the end which is enclosed in the centre of the 
cylinder is its terminal extremity ; and the portion between 
the extremities the body ; a roller has also two surfaces, 
external and internal. 

Dimensions of Bandages. 

Bandages vary in length and width according to the pur- 
poses for which they are employed, and in practice it will be 
found that a small variety of bandages will be amply suffi- 
cient for the application of the ordinary surgical dressings. 

The following list comprises those most frequently used 
and will show their dimensions : 

Bandage one inch wide, three yards in length, for ban- 
dages for the hand, fingers, and toes. 

Bandage two inches wide, six yards in length, for head 
bandages and for the extremities in children. 

Bandage two and a half inches wide, seven yards in 
length, for bandages of the extremities in adults ; a roller of 
this size is the one most generally used. 

Bandage three inches wide, nine yards in length, for ban- 
dages of the thigh, groin, and trunk. 

Bandages four inches wide, ten yards in length, for ban- 
dages of the trunk. 

General Rules for Bandaging. 

In applying a roller bandage the operator should place 
the external surface of the free extremity of the roller upon 
the part, holding it in position with the fingers of the left 
hand until fixed by a few turns of the roller, the cylinder 
being held in the right hand by the thumb and fingers ; for 
thus as the bandage is unwound it rolls into the operator's 



18 BANDAGING. 

hand, thereby giving him more control of it ; care should 
also be taken that the turns are applied smoothly to the sur- 
face, and that the pressure exerted by each turn is uniform. 

If a bandage be applied to a limb the surgeon should see 
that the part is in the position it is to occupy as regards 
flexion and extension when the dressing is completed, for a 
bandage applied when the limb is flexed will exert too much 
pressure when the limb is extended, and then may, by the 
pressure it exerts, become a matter of discomfort or even of 
danger to the patient, or if applied to an extended limb 
will become uncomfortable upon flexion. 

My experience has been that, as a rule, those who have 
had little experience with the application of the roller ban- 
dage are apt to apply their bandages too tightly, and this 

Fig. 5. 




Bandage scissors. 

may lead to disastrous consequences, especially in the dress- 
ing of fractures. Professor Ashhurst, in his clinical teach- 
ing, advises students to make use of a larger number of 
turns of a bandage in securing fracture dressings rather 
than to depend upon a few turns too firmly applied ; advice 
which certainly conduces to the safety and comfort of the 
patient. When the bandage has been applied the terminal 
extremity should be secured by a pin or safety-pin applied 
transversely to the bandage, and if a pin be used its point 
should be buried in the folds of the bandage ; if the bandage is 
a narrow one, the end may be split and the two tails result- 
ing may be secured around the part by tying. In removing 
a bandage the folds should be carefully gathered up in a 
loose mass as the bandage is unwound, the mass being trans- 



VARIETIES OF BANDAGES. 19 

ferred rapidly from one hand to the other, thus facilitating 
its removal and preventing the part from becoming entangled 
in its loops. If it is desirable to cut the bandage to remove 
it, the use of scissors made for this purpose will be found 
most satisfactory. (Fig. 5.) 

Varieties of Bandages. 

The Circular Bandage. 

This bandage consists of a few circular turns around a 
part, each turn covering accurately the preceding turn. 
This variety of bandage may be used to retain a dressing 
to a limited portion of the head, neck, or limbs, to make 
compression upon the veins of the arm before performing 
venesection. (Fig. \\ b.) 

The Oblique Bandage. 

In this form of bandage the turns are carried obliquely 
over the part, leaving uncovered spaces between the suc- 

Fig. Ci. 




Oblique bandage. 

cessive turns. (Fig. 6.) Its principal use is for the appli- 
cation of temporary dressings. 

The Spiral Bandage. 

In this bandage the turns are carried around the part in 
a spiral direction, each turn overlapping a portion of the 



20 



BANDAGING. 



preceding one, usually one-third or one-half. (Fig. 7.) This 
bandage may be used to cover a part which does not in- 
crease too rapidly in diameter, for instance the abdomen, 
chest, or arm. 

Fig 7. 




Spiral bandage. 

-The Spiral Reversed Bandage. 

This bandage is a spiral bandage, but differs from the 
ordinary spiral bandage in having its turns folded back or 

Fig. 3. 




Method of making reverses. 



reversed as it ascends a part, the diameter of which gradu- 
ally increases. By its use it is possible to cover by spiral 



VARIETIES OF BANDAGES. 21 

turns a part conical in shape, so as to make equable pressure 
upon all parts of the surface. The reverses are made as 
follows : After fixing the initial extremity of the roller, as 
the part increases in diameter the bandage is carried off a 
little obliquely to the axis of the limb for from four to six 
inches ; the index finger or thumb of the disengaged hand 
is placed upon the body of the bandage to keep it securely 
in place upon the limb, the hand holding the roller is car- 
ried a little toward the limb to slacken the unwound portion 
of the bandage, and by changing the position of the hand 
holding the bandage from extreme supination to pronation 
the reverse is made. (Fig. 8.) Care should be taken not to 
attempt to make the reverse while the bandage is tense, for 
by so doing the bandage is twisted into a cord which is un- 
sightly and uncomfortable to the patient, instead of forming 
a closely fitting reverse. 

The reverse should be completed before the bandage is 
carried around the limb, and when it has been completed 
the bandage may be slightly tightened so as to conform to 
the part accurately. 

The reverses should be in line to have the bandage pre- 
sent a good appearance, and care should be taken that the 
reverses should not be made over salient parts of the 
skeleton, for if they occupy such positions they cause creases 
in the skin and become uncomfortable to the patient. 

To make reverses neatly and to have them in line requires 
skill and practice ; a well applied spiral reversed bandage is 
a test of a competent bandager. 

Spica Bandages. 

When the turns of the roller cross each other in the 
form of the Greek letter lambda, leaving the previous turn 
about one-third uncovered, the bandage is known as a spica 
bandage. (Fig. 9, a.) These spica bandages are especially 
serviceable as a means of retaining surgical dressings upon 
particular portions of the surface of the body, such as to 
the shoulder, groin, or foot. 

2* 



22 



BANDAGING. 

Fig. 9. 




Spica bandage. 



Circular bandai 



Figure-of-eight Bandage. 

This bandage receives its name from the turns being ap- 
plied so as to form a figure-of-eight. This method of appli- 
cation is made use of in the Barton's bandage, the bandages 
of the knee and elbow, and many other bandages. 

Fig. 10. 




Recurrent bandage. 



Recurrent Bandage. 

This bandage derives its name from the fact that the 
roller after covering a certain part of the surface is reflected 
and brought back to the point of starting ; it is then reversed 



COMPOUND BANDAGES. 



23 



and carried toward the opposite point, and this manipulation 
is continued until the part is covered by these recurrent 
turns, which are then secured by a few circular turns. (Fig. 
10.) This is the bandage usually employed in the dressing 
of stumps. 

Compound Bandages. 

These bandages are usually formed of several pieces of 
muslin or other material, and are employed to fulfil some 
special indication in the application of dressings to particular 
parts of the body. The most useful of the compound ban- 
dages are the T-bandages and the many-tailed bandages. 

T-bandages. 

The single T-bandage consists of a horizontal band to 
which is attached, about its middle, another having a vertical 
direction ; the horizontal piece should be about twice the 

Fig. 11. 




Single T-bandage. 



length of the vertical piece. (Fig. 11.) The single T- 
bandage may be used to retain dressings to the head, the 
horizontal piece being passed around the head from the 
occiput to the forehead, the vertical piece being passed over 
the head and secured to the horizontal piece; the shape and 
width of the two pieces being varied according to the indica- 



24 



BANDAGING 



tions. In applying dressings to the anal region, or peri- 
neum, or in securing a catheter in a perineal wound, the single 



Fig. 12. 




Single T-ba adage for chest. 
Fig. 13. 



Lfr4JI 




T-bandage of groin. 



T-bandage will be found most useful. In applying a T- 
bandage for this purpose the body of the bandage is placed 



COMPOUND BANDAGES. 



25 



over the spine, just above the pelvis, and the horizontal 
portion is tied around the abdomen. The free extremity is 
split into two tails for about two-thirds of its length, and is 
carried over the anal region and brought up between the 
thighs, the terminal strips passing one on each side of the 
scrotum and being secured to the horizontal strip in front. 
The single T-bandage may be variously modified according 
to the indications which are to be met; for instance, in 
applying a dressing to the breasts the horizontal strip passing 
around the chest may be made ten or twelve inches in width, 
the vertical strip, two inches in width, passes from the back 
over the shoulder and is. secured to the horizontal strip in 
front. (Fig. 12.) The single T-bandage may be variously 
modified, according to the ideas of the surgeon, so as to meet 
the indications presented in special cases. For the groin a 
piece of muslin six inches wide at its base and thirty inches 
long is sewed to a horizontal strip of muslin one and a 
half yards long and two inches in width. It may be ap- 
plied as in Fig. 13 to hold a dressing to this part 

Double T-bandage. 

Fig. 14. 




Double T-bandage. 



The double T-bandage differs from the single bandage in 
having two vertical strips attached to the horizontal strip, 



26 BANDAGING. 

and it may be used for much the same purposes as the single 
T-bandage. (Fig. 14.) It may be conveniently used for 
retaining dressings to the chest, breasts or abdomen ; when 
used for this purpose the horizontal portion should be from 
eight to twelve inches wide and long enough to pass one and 
a quarter times about the chest ; two vertical strips, two 
inches wide and twenty inches long, should be attached to 
the horizontal strip a short distance apart near its middle. 
In applying this bandage to the chest, the horizontal strip 
is placed around the chest so that the vertical strips occupy 
a position on either side of the spine ; the overlapping end 
of the horizontal portion is secured by pins or safety-pins, 
and the vertical strips are next carried one over either 
shoulder and secured to other portions of the bandage in 
front of the chest. (Fig. 15.) 

Fig. 15. 




Double T-bandage of chest. 

The double T-bandage may also be used to secure dress- 
ings to the nose, in which event the strips should be quite 
narrow, about one inch in width, and should be applied as 
shown in Fig. 16. 

Many-tailed Bandages or Slings. 

These bandages are prepared from pieces of muslin of 
various lengths and breadths, which are split at each ex- 



COMPOUND BANDAGES. 



27 



treinity into two, three, or more tails up to within a few 
inches of their centres, their width and length being regu- 
lated by the part of the body to which they are applied. 

The four-tailed bandage may be found useful as a tem- 
porary dressing in cases of fracture of the jaw, or to hold 



Fig. l! 



Fig. i; 





Double T-bandage of nose. 



Four-tailed bandage of chin. 



dressings to the chin. It may be FlG - * 

prepared by taking a portion of 
a roller bandage three inches wide 
and one yard in length, and split- 
ting each extremity up to within 
two inches of the centre; it is then 
applied as seen in Fig. 17. 

The four-tailed bandage may 
also be used to retain dressings to 
the scalp, and can be prepared by 
taking a piece of muslin one yard 
and a quarter long and six or 
eight inches in width, splitting it 
at each extremity into two tails 
within three inches of the cen- 
tre ; it may then be applied as seen in Fig. 18. 

The four-tailed bandage may also be used in the 
rary dressing of fractures of the clavicle — the body 




Four-tailed bandage of head. 



tempo- 
of the 



28 



BANDAGING. 



bandage being placed upon the elbow of the injured side, 
two tails passing around the body, fixing the arm to the 
side, and two tails passing over the sound shoulder. 

The many-tailed bandage may also be used for holding 
dressings in contact with the abdomen or trunk, and is the 
bandage which many surgeons employ to hold the dressings 
to a laparotomy wound, and to give support to the abdom- 
inal walls after this operation. In preparing this bandage, 
a strip of muslin, one and a half yards in length and eigh- 
teen to twenty inches in width, is required, and the extremi- 
ties may be split so as to form an eight-tailed bandage. In 
applying this bandage to the abdomen the body is placed 
upon the patient's back and the tails are brought around 
the abdomen and overlap each other, and when sufficiently 
firmly drawn to make the desired amount of pressure they 
are secured by means of safety-pins. 

Handkerchief Bandages. 

The use of handkerchiefs or square pieces of muslin for 
the temporary or permanent dressing of wounds, fractures, 





Fig. 


19. 


_-J> v 


i i ii! 

1 1 I 1 


N ' 


£— — -" 1 -^ yvz 4 i 




j: \ j=M! 1 


rr_j 


nr if 


L._\_.jL 

--^tV--! 1 !!:', 


•j 


—== ; ;|i 


=== lt l ^^ 






\ 



Fig. 20. 



The square. 



The oblong. 



or dislocations was advocated many years ago by M. Mayor, 
a Swiss surgeon, who wrote an extensive work upon this 
subject, in which he reduced their application to a system. 



HANDKERCHIEF BANDAGES. 



29 



He employed a handkerchief or square piece of muslin, and 
by various modifications in the application of these devel- 
oped a number of very ingenious bandages. 

The various forms which the handkerchief or square 
(Fig. 19) is made to assume are as follows: The oblong, 
made by folding the square once or twice on itself (Fig. 20). 
The triangle, made by bringing together the diagonal angles 
of the square (Fig. 21). The line of folding is known as 

Fig. 21. 




The triangle. 

the base, the angle opposite the base the apex, and the other 
angles the extremities. 

The cravat is prepared from the triangle by bringing the 
apex to its base, and folding it a number of times upon 
itself until the desired width is obtained. (Fig. 22.) 

Fig. 22. 



The cravat. 
Fig. 23. 

The cord. 



The cord is formed from the cravat twisted upon itself 
(Fig. 23). The names of the various handkerchief ban- 



30 



BANDAGING. 



dages are derived from the shape of the handkerchiefs used 
and the parts to which they are applied ; the names serve 
as guides in their application. It is to be remembered that 
the base of the triangle or the body of the cravat is to be 
placed upon the portion the designation of which forms the 
final portion of the name of the bandage ; thus, in the fronto- 
occipital triangle, the shape of the handkerchief is given, 
and we know that the base of the triangle is to be applied to 
the forehead and then pass to the occiput. In using the 
cravats the same rule applies ; thus, in . the bis-axillary 



Fig. 24. 



Fig. 25. 




Bis-axillary cravat. 



Cruro-pelvic triangle. 



cravat, the body of the cravat is to be placed in the axilla 
of the affected side, the extremities crossed over the corre- 
sponding shoulder and carried over the chest, one before, the 
other behind, to the axilla of the opposite side, where they 
are secured. To apply the bis-axillary cravat (Fig. 24), a 
piece of muslin a yard and a quarter long and eighteen 
inches in width folded into a cravat is required ; this ban- 
dage may be used to hold dressing to the axilla. 

The Cruro-pelvic Triangle. 

This bandage may be applied with a piece of muslin 
folded into a triangle a yard and a half long and two feet 



HANDKERCHIEF BAXDAGES. 31 

deep. It is applied by placing the base of the triangle 
obliquely across the right groin and conducting the superior 
extremity around the left side, across the loins to the right 
groin, when it is secured. The inferior end should be car- 
ried around the upper part of the right thigh between it 
and the scrotum, to a point near the superior extremity, and 
fastened with a pin (Fig. 25); this bandage maybe em- 
ployed to secure dressings to the groin, hip, and upper por- 
tion of the thigh. 

Barton's Handkerchief. 

This dressing may be employed to make extension in 
cases of fracture of the leg or thigh. It is applied by taking 
a handkerchief folded into a narrow cravat and placing the 
body of it on the extremity of the os calcis below the inser- 
tion of the tendo Achillis, so that two-thirds of the cravat 
comes around under the outer malleolus, and the other third 
remains on the inside. The inside portion remaining par- 
allel with the sole of the foot, the outside piece is carried 
over the instep and passed around it so as to form a knot, 
and also passed under the sole of the foot to be turned 
around the first turn and to form another knot at the meta- 
tarsal articulation, when both ends are carried off perpen- 
dicularly from the foot. 

I have described a few of the many very ingenious ban- 
dages devised by Mayor to substitute the use of the roller 
bandage, which will give the student some idea of their 
design and application. It is well to bear in mind this 
system of dressing, for the occasion might occur in which 
the other means of bandaging could not be obtained, and 
the use of handkerchiefs might answer a useful purpose as 
temporary dressings. I think their principal use is for 
temporary dressings, and I do not think they will ever take 
the place of the roller bandage, which can be applied with 
much greater nicety and exactness^ and certainly presents a 
much neater appearance. 



32 REGIONAL BANDAGES. 

KEGIONAL BANDAGING. 

Bandages for the Head and Neck. 

Barton's Bandage. 

Roller Two Inches in Width, Six Yards in Length. 

Application. — The initial extremity of the roller should 
be placed on the head just behind the mastoid process and 
the bandage should then be carried under the occipital pro- 
tuberance obliquely upward under and in front of the 
parietal eminence across the vertex of the skull, then down- 
ward over the zygomatic arch, under the chin, thence up- 
ward over the opposite zygomatic arch and over the top of 

Fig. 26. 




Barton's bandage. 

the head, crossing the first turn, which was made as nearly 
as possible in the median line of the skull, carrying the 
turns of the roller under the parietal eminence to the point 
of commencement. The bandage is then passed obliquely 
around under the occipital protuberance and forward under 
the ear to the front of the chin, thence back to the point 



MODIFIED BARTON'S BANDAGE. 33 

from which the roller started. These figure-of-eight turns 
over the head and the circular turns from the occiput to the 
chin should be repeated, each turn exactly overlapping the 
preceding one until the bandage is exhausted. (Fig. 26.) 
The extremity should then be secured by a pin ; and pins 
should be introduced at the points where the turns cross 
each other to give additional fixation to the bandage. In 
applying the bandage care should be taken to see that the 
turns overlap each other exactly and that the turns passing 
over the vertex cross as near as possible in the median line 
of the skull. 

Modified Barton's Bandage. 

To obtain additional security in the application of the 
Barton's bandage a turn of the bandage passing from the 
occiput to the forehead may be made, this turn being inter- 
posed between the turns of the bandage as ordinarily applied. 




Modified Barton's bandage. 



(Fig. 27.) In applying this bandage after the first set of 
turns has been completed, that is after the bandage has been 
brought back to the occiput, the bandage is carried forward 
upon the head just over the ear, around the forehead and 
backward above the ear on the opposite side to the occiput; 



34 REGIONAL BANDAGES. 

this being done, the ordinary figure-of-eight and circular 
turns are made, and when these have been completed another 
occipito-frontal turn may be made as described above, and 
this may be repeated as often as is desired until the bandage 
is exhausted, when the extremity is fastened with a pin, and 
pins are also introduced at all points at which the turns 
cross. 

Use. — This bandage is one of the most useful of the 
bandages of the head, being employed to secure fixation 
of the jaw in cases of fracture or dislocation, and for the 
application of dressings to the chin. I have also employed 
it in place of the head-gear in slinging patients for the 
application of the plaster- of-Paris bandage in cases of 
disease of the spine, a stout cord or a piece of bandage 
about three inches wide and one yard long being passed 
under the turns crossing over the vertex ; this cord is then 
secured to the cross-bar of the extension apparatus ; this 
will be found quite as comfortable to the patient as the 
ordinary head-gear employed and much less likely to slip 
out of place and interfere with the breathing of the patient. 
A firmly applied Barton bandage holds the jaws so closely 
together that care should betaken in applying it to patients 
who are under the influence of an anaesthetic, for if vomit- 
ing occurs the material may not be able to escape from the 
mouth and suffocation might occur unless the bandage were 
promptly removed. This accident I once saw occur and 
the patient's condition was alarming until the bandage was 
cut, allowing the jaw to be opened and the contents of the 
mouth to escape. 

Gibson's Bandage. 
Boiler Two Inches in Width, Six Yards in Length. 

Application. — The initial extremity of the roller should 
be placed upon the vertex of the skull in a line with the 
anterior portion of the ear ; the bandage is then carried 
downward in front of the ear to the chin, and passed under 
the chin, and is carried upward on the same line until it 



35 

reaches the point of starting. The same turns are repeated 
until three complete turns have been made ; the bandage is 
then continued until it reaches a point just above the ear, 
when it is reversed and is carried backward around the 
occiput, and is continued around the head and forehead until 
it reaches its point of origin ; these circular turns are con- 
tinued until three turns have been made. When the ban- 
dage reaches the occiput, having completed the third turn, 

Fig. 28. 




Gibson's bandage. 

it is allowed to drop down to the base of the skull, and it is 
then carried forward below the ear and around the chin, 
being brought back upon the opposite side of the head and 
neck to the point of origin ; these turns are repeated until 
three complete turns have been made, and upon the comple- 
tion of the third turn the bandage is reversed and carried 
forward over the occiput and vertex to the forehead, and its 
extremity is here secured with a pin. Pins should also be 
applied at the points where the turns of the bandage cross 
each other. (Fig. 28.) 

Use. — This bandage may be used to fix the lower jaw in 
cases of fracture or dislocation of the jaw, but is more apt to 
change its position, and is therefore not so satisfactory as the 
Barton's bandage for this purpose. 



36 kegional bandages. 

Oblique Bandage of Angle of the Jaw. 

Roller Two Inches in Width, Six Yards in Length. 

Application. — The initial extremity of the roller is 
placed just in front of and above the left ear, and if the 
left angle of the lower jaw is to be covered in, the bandage 
is to be carried from left to right, making two complete 
turns around the cranium from the occiput to the forehead. 
If the right angle of the lower jaw is to be covered in, the 
turns should be made in the opposite direction. 

Having made two turns from the occiput to the forehead, 
the bandage is allowed to drop down upon the neck, and is 
carried forward under the ear and under the chin to the angle 

Fig. 29. 




Oblique bandage of angle of the jaw. 

of the jaw ; it is now carried upward close to the edge of the 
orbit, and obliquely over the vertex of the skull, then down be- 
hind the right ear, continuing this oblique turn under the 
chin to the angle of the left jaw, where it ascends in the same 
direction as the previous turn. Three or four of these ob- 
lique turns are made, each turn overlapping the preceding 
one and passing from the edge of the orbit toward the ear 



RECURRENT BANDAGE OF THE HEAD. 37 

until the space is covered in; the bandage is then carried to 
a point just above the ear on the opposite side, is reversed, 
and finished with one or two circular turns from the occiput 
to the forehead, the extremity being secured by a pin. 
(Fig. 29.) 

Use. — This will be found to be one of the most useful of 
the head bandages ; it may be used with a compress in 
ti eating fractures of the angle of the lower jaw, for holding 
dressings to the lower part of the chin and to the vault of 
the cranium, and is especially useful in retaining dressings 
to the sides of the face and the parotid region. As before 
stated, it may be applied to cover either the right or left 
side of the face, and, by reason of the oblique turns, holds 
its position most securely, having little tendency to become 
displaced. 

Recurrent Bandage of the Head. 

Roller Two Inches in Width, Eight Yards in Length. 

Application. — The initial extremity of the roller is 
placed upon the lower part of the forehead and the bandage 
is carried twice around the head from the forehead to the 
occiput to secure it. When the bandage is brought back to 
the median line of the forehead it is reversed and the re- 
versed turn is held by the finger of the left hand while the 
roller is carried over the top of the head along the sagittal 
suture to a point just below the occipital protuberance; here 
it is reversed again and the reverse is held by an assistant 
while the roller is carried back to the forehead in an elliptical 
course, each turn covering in two-thirds of the preceding 
turn. These turns are repeated with successive reverses at 
the forehead and occiput until one side of the head is com- 
pletely covered in, and when this is accomplished a circular 
turn is made from the forehead to the occiput to hold the 
reverses in place. 

The opposite side of the head is next covered in by 
elliptical reversed turns made in the same manner, and 
when this has been accomplished two or three circular turns 

3 



38 REGIONAL BANDAGES. 

are carried around the head from the forehead to the occiput 
to fix the previous turns. Pins should be applied at the 
forehead and occiput at the points where the reversed turns 
concentrate. (Fig. 30.) 

Fig. 30. 




Recurrent bandage of the head. 

Use. — This bandage when well applied is one of the 
neatest of the head bandages, and it will be found useful to 
retain dressings to the vault of the cranium in the treatment 
of wounds of the scalp in this region. It will also be found 
of service in holding dressings to fractures of the cranium 
and to wounds after the operation of trephining. In restless 
patients it will sometimes become displaced, and it may be 
rendered more secure by pinning a strip of bandage to the 
circular turn in front of the ear and carrying it down under 
the chin and up to a corresponding point on the opposite 
side, where it is pinned to the circular turn ; or one or two 
oblique turns passing from the circular turn over the vertex 
of the skull downward behind the ear, under the chin and 
up to the circular turn in front of the ear may be applied. 
The course of these turns is the same as those employed in 
the oblique bandage of the angle of the jaw, the extremity 
being secured by a pin. 



V-BANDAGE OF THE HEAD. 39 

V-BANDAGE OF THE HEAD. 

Roller Tivo Indies in Width, Four Yards in Length. 

Application. — The initial extremity of the roller is se- 
cured by two turns of the bandage around the cranium from 
the forehead to the occiput, and when the roller reaches the 
occipital protuberance it is allowed to drop slightly a little 
below this and is carried forward below the ear around the 

Fig. 31. 




V-bandage of the head. 

front of the chin and lower lip, then backward to the point 
of starting. These turns passing from the occiput to the 
forehead and from the occiput to the chin are alternately 
made until a sufficient number have been applied, and the 
extremity is secured by a pin over the occiput. (Fig. 31.) 

This bandage may be modified by carrying the turns from 
the occiput forward under the ear and around the upper lip 
and back to the occiput and alternating these turns with the 
occipito-frontal turns ; if employed in this way a bandage of 
one and one-half inches in width should be used. 

Use. — This bandage may be employed to hold dressings 
to the front of the chin, to the upper and lower lips in cases 



40 REGIONAL BANDAGES. 

of wounds, or to give support to these parts after plastic 
operations. 

Head and Neck Bandage. 

Roller Two Inches in Width, Four Yards in Length. 

Application. — The initial extremity of the roller is 
placed upon the forehead and carried backward just above 
the ear to the occiput and is then brought forward around 
the opposite side of the head to the point of starting. Two 

Fig. 32. 




Head and neck bandage. 

of these circular turns are made to fix the bandage, and 
when it is carried back to the occiput it is allowed to drop 
down slightly upon the neck and is then carried around the 
neck, the turns around the head alternating with the neck 
turns until a sufficient number of these have been applied, 
when the extremity of the bandage is secured by a pin at 
the point of crossing of the turns at the back of the head. 
(Fig. 32.) 



CROSSED BANDAGE OF ONE EYE. 41 

Use. — This bandage may be found useful in securing 
dressings to the anterior or posterior portion of the neck or 
to the region of the occiput. 

Care should be taken to apply it in such a manner that 
too much pressure is not made by the turns around the neck, 
which would be uncomfortable to the patient, and might 
seriously interfere with respiration. 

Crossed Bandage of One Eye. 

Roller Two Inches in Width, Four Yards in Length. 

Application. — The initial extremity of the bandage is 
placed upon the forehead and fixed by two circular turns 
passing around the head from the occiput to the forehead ; 

Fig. 33. 




Crossed bandage of one eye. 

the roller is then carried back to the occiput and passed 
around this and brought forward below the ear, and passing 
over the outer portion of the cheek is carried upward to the 
junction of the nose with the forehead, and is then conducted 
over the parietal protuberance downward to the occiput; a 
circular fronto-occipital turn is next made, and when the ban- 
dage is brought back to the occiput it is brought forward 



42 REGIONAL BANDAGES. 

again to the cheek and ascends to the forehead, covering in 
two-thirds of the previous turn, and is again conducted back 
to the occiput ; these turns are repeated, the oblique turns 
covering the eye alternating with circular turns around the 
head until the eye is completely enclosed (Fig. 33), and the 
bandage is finished by making a circular turn about the head 
and introducing a pin to secure its extremity. It will be 
found more comfortable to the patient to include the ear on 
the same side on which the eye is covered in the turns of the 
bandage. 

Use. — This bandage will be found useful in retaining 
dressings to one eye. It will be more comfortable to the 
patient if a flannel roller be used to apply this bandage, as 
well as the bandage which includes both eyes. 

Crossed Bandage of Both Eyes. 

Roller Two Inches in Width, Six Yards in Length. 

Application. — The initial extremity of the roller is 
placed upon the forehead and secured by two circular turns 
of the bandage, passing around the head from the forehead to 
the occiput ; the roller is then carried downward behind the 
occiput and brought forward below the ear to the upper por- 
tion of the cheek ; it is then carried upward to the junction 
of the nose with the forehead and conducted over the parietal 
protuberance to the occiput ; a circular turn is now made 
around the head from the occiput to the forehead, and the 
roller is carried from the occiput over the parietal protuber- 
ance of the opposite side forward to the junction of the nose 
with the forehead, then downward over the eye and outer 
portion of the cheek below the ear and back to the occiput ; 
a circular turn around the head is next made, and this is fol- 
lowed by a repetition of the previous turns, ascending over 
one eye, descending over the other eye, each turn alternat- 
ing with a circular turn around the head. These turns are 
repeated until both eyes are covered in, and the bandage is 
finished by making a circular turn around the head, the ex- 



OCCIPITO-FACIAL BANDAGE. 43 

tremity being secured by a pin. (Fig. 34.) In this bandage 
both ears may be covered in, or left uncovered. 

Fig. 34. 




Crossed bandage of both eyes. 

Use. — This bandage may be used to apply dressings to 
both eyes, and both of these bandages covering the eyes are 
used where it is desired to make pressure ; but, for the sim- 
ple application of a light dressing or of a bandage for the 
exclusion of light, the Liebreich's bandage (Fig. 68) will be 
found more comfortable to the patient. 

Occipitofacial Bandage. 

Boiler Two Incites in Width, Four Yards in Length. 

The initial extremity of the roller is placed upon the 
vertex of the head, and the bandage is carried downward in 
front of the ear and under the jaw, and upward upon the 
opposite side in the same line to the vertex ; two or three 
of these turns are made, one turn accurately covering in 
the other, and a reverse is made just above and in front 
of the ear, and two or three turns are made around the 
head from the occiput to the forehead, which completes the 



44 REGIONAL BANDAGES. 

bandage. (Fig. 35.) Pins should be inserted at the points 
where the turns of the bandage cross each other. 

Fig. 35. 




Occipito-facial bandage. 

Use. — This bandage is employed to secure dressings to 
the vertex, temporal, occipital, or frontal regions. 

Oblique Bandage of the Head. 

Roller Two Inches in Width, Four Yards in Length. 

The initial extremity of the bandage is placed upon the 
forehead, and is secured by two circular turns passing around 
the head from the forehead to the occiput. From the occiput 
the bandage is carried obliquely over the highest part of the 
lateral aspect of the head, which is to be covered in, and is 
passed over the forehead and back to the occiput, and is 
then carried to the forehead by a circular turn, then con- 
ducted obliquely over the other side of the head and back 
to the occiput. These turns are repeated, so that each suc- 
ceeding turn covers in three-fourths of the preceding turn 
until the sides of the head are covered in by descending 
turns, and the bandage is completed by a circular turn 



SPIRAL BANDAGE OF THE FINGER. 45 

passing around the head from the forehead to the occiput. 
(Fig. 36.) This bandage may be applied with descending 
or ascending turns. 

Fig. 36. 




Oblique bandage of the head. 

Use. — This bandage is employed to make pressure upon 
or to hold dressings to the lateral aspects of the head. 



Bandages of the Upper Extremity. 

Spiral Bandage of the Finger. 

Roller One Inch in Width, One and a Half Yards in 
Length. 

Application. — The initial extremity of the roller is 
secured by two or three turns around the wrist; the bandage 
is then carried obliquely across the back of the hand to the 
base of the finger to be covered in, then to its tip by oblique 
turns ; a circular turn is then made and the finger is cov- 
ered by ascending spiral or spiral reversed turns until its 
base is reached ; the bandage is then carried obliquely across 
the back of the hand and finished by one or two circular 

4* 



46 REGIONAL BANDAGES. 

turns around the wrist; the extremity may be pinned or 
may be split into two tails, which are tied around the wrist. 
(Fig. 37.) 

Fig. 37. 




Spiral bandage of the finger. 

Use. — This bandage is employed to retain dressings upon 
the finger and to secure splints in the treatment of fractures 
or dislocations of the phalanges. 

Gauntlet Bandage. 

Boiler One Inch in Width, Three Yards in Length. 

Application. — The initial extremity of the roller is fixed 
at the wrist by one or two circular turns of the bandage ; it 
is then carried down to the tip of the thumb by an oblique 
turn of the roller, and this is covered in by spiral or spiral 
reversed turns to the metacarpo-phalangeal articulations ; 
the roller is then carried back to the wrist and a circular 
turn is made around it, and the bandage is now carried 



GAUNTLET BANDAGE, 



47 



down to the tip of the next finger by an oblique turn, 
which is covered-in in the same manner. When all the 
fingers have been covered in, the bandage is finished by 
circular turns around the hand and wrist. (Fig. 38.) 

Fig. 38. 




Gauntlet bandage. 



Use. — This bandage may be employed to apply dressings 
to the fingers and hand in case of wounds or fractures. It 
was formerly much employed in the treatment of burns of 
the fingers to prevent the opposed ulcerated surfaces from 
adhering, but its use for this purpose has been supplanted by 
wrapping each finger in a separate dressing and applying a 
dressing over the whole with a few recurrent and spiral turns 
of a wide roller, the application of this dressing being much 
less painful to the patient, and being at the same time equally 
satisfactory. 



48 REGIONAL BANDAGES. 



Demi-gauntlet Bandage. 

Roller One Inch in Width, Four Yards in Length. 

Application. — The initial extremity of the bandage 
should be placed upon the wrist and fixed by two circular 
turns passing from the ulnar to the radial side ; then carry 
the roller obliquely across the back of the hand to the base 




Demi-gauntlet bandage. 

of the index finger, pass the bandage around this and carry 
the roller back to the wrist, making a circular turn ; it 
should then be carried obliquely across the hand to the base 
of the next finger, and so successively until the base of 
each of the fingers and of the thumb has been included ; 
the bandage is then completed by a circular turn around 
the wrist. (Fig. 39.) 

The demi-gauntlet bandage may be also applied in such 
a manner as to cover the palm of the hand and leave the 
back of the hand uncovered. 



SPIOA BANDAGE OF THE THUMB. 49 

Use. — This bandage may be employed to retain light 
dressings to the dorsal or palmar surface of the hand. 

Spica Bandage of the Thumb. 
Roller One Inch in Width, Three Yards in Length. 

Application. —The initial extremity of the roller is 
placed upon the wrist and fixed by two circular turns ; then 
carry the roller obliquely over 
the dorsal surface of the thumb 
to its distal extremity ; next 
make a circular or spiral turn 
around the thumb, and carry the 
bandage upward over the back of 
the thumb to the wrist, around 
which a circular turn should be 
made. The roller is next car- 
ried around the thumb and wrist, 
m akin or figure-of-eight turns, each 
turn overlapping the previous one 
two-thirds as it ascends the 
thumb, and each figure-of-eight 
turn alternating with a circular 
turn about the wrist. These 

bpica bandage of the thumb. 

turns are repeated until the thumb 

is completely covered in with spica turns, and the bandage 

is finished by a circular turn around the wrist. (Fig. 40.) 

Use. — This bandage is employed to apply dressings to the 
dorsal surface of the thumb, and for the retention of splints 
in the dressing of fractures or dislocations of the bones of 
the thumb. 




50 regional bandages. 

Spiral Reversed Bandage of the Upper Extremity. 

Roller Two and a Half Inches in Width, Seven 
Yards in Length. 

Application. — The initial extremity of the roller is 
placed upon the wrist, and secured by two turns around the 
wrist ; the bandage is then carried obliquely across the back 
of the hand to the second joint of the fingers, where a circular 
turn should be made ; the hand is covered in by two or three 
ascending spiral or spiral reversed turns. When the thumb 
has been reached, its base and the wrist are covered in by 

Fig. 41. 




Spiral reversed bandage of the upper extremity. 

two figure-of-eight turns'; the bandage is then carried up 
the forearm by spiral and spiral reversed turns until the 
elbow is reached ; this may be covered in with spiral re- 
versed turns, and the bandage is next carried up the arm 
with spiral reversed turns to the axilla. (Fig. 41.) If, on 
reaching the elbow, the arm is bent or is to be flexed in the 
subsequent dressing, the elbow should be covered in with 
figure-of-eight turns, and when this has been done the arm 
above may be covered in with spiral reversed turns. When 
properly applied, the reverses should be in line, and should 
not be made over the prominent ridge of the ulna. 

Use. — This is one of the most generally employed of all 



FIGURE-OF-EIGHT BANDAGE OF ELBOW. 51 

the roller bandages ; it constitutes the primary roller which 
is applied in the dressing of fractures of the humerus, and 
is also the bandage employed in holding dressings to the 
arm and forearm, and in securing splints to these parts in 
the treatment of fractures and dislocations. 

Figure-of-eight Bandage of the Elbow. 



Roller Two Inches in Width, Four Yards in Length. 



Application.- 
placed upon the 



—The initial extremity of the bandage is 
forearm a short distance below the elbow- 



joint, and fixed by one or two circular turns, 



the arm being 



Fig. 42. 




Figure-of-eight bandage of the elbow. 

flexed. The bandage is then carried by an oblique turn 
across the flexure of the elbow-joint, and passed around the 
arm a few inches above the elbow ; a circular turn is then 
made, and the roller is next carried across the flexure of the 
elbow and passed around the forearm. These turns are re- 
peated, the turns from the forearm ascending and those from 
the arm descending, each set of turns crossing in the flexure 



52 



REGIONAL BANDAGES. 



of the elbow until it is covered in, and a final turn is passed 
circularly around the elbow-joint. (Fig. 4*2.) 

Use. — This bandage is often employed as a part of the 
spiral reversed bandage of the upper extremity when the 
arm is to be flexed, and is also used to hold dressings to the 
region of the elbow-joint. It was formerly much used to 
hold the compress upon the wound resulting from venesec- 
tion at the elbow. 



Spica Bandage of the Shoulder (Ascending). 

Holler Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — The initial extremity of the roller is 
placed obliquely upon the outer surface of the arm opposite 
the axillary fold, and fixed by one or two circular turns. If 



Fig. 43. 



Fig. 44. 





Spica bandage of the shoulder 
(ascending). 



Spica bandage of (he shoulder 
(descending). 



the right shoulder is to be covered, the bandage is next car- 
ried across the front of the chest to the axilla of the oppo- 
site side, then around the back of the chest to the point of 
starting upon the arm ; then conduct the roller around the 
arm of this side up over the shoulder, across the front of the 
chest, through the opposite axilla and back over the pos- 
terior surface of the chest to the point of starting ; continue 



SPICA BANDAGE OF THE SHOULDER. 53 

to make these ascending turns, each turn overlapping the 
preceding turn about two-thirds until the shoulder is covered 
in (Fig. 43), when the extremity of the bandage may be 
secured by a pin at the point of ending, or the last turn 
may be carried from the shoulder around the back of the 
neck and brought forward over the opposite shoulder and 
pinned to the turns which pass around the axilla It should 
be remembered that the turns of the roller overlap each other 
exactly in the opposite axilla, and it will be found more com- 
fortable to the patient to apply a little cotton wadding in the 
axilla to prevent the bandage from excoriating the skin of 
this part. Care should be taken to see that the turns are 
made in such a manner that the spica turns occupy, as nearly 
as possible, the median line of the shoulder. When this 
bandage is applied to the left shoulder, after fixing the ini- 
tial extremity by circular turns around the arm, the roller 
should be carried over the back of the chest to the axilla of 
the opposite side and then brought back to the point of start- 
ing ; the succeeding turns are then applied in the same 
manner. 



Spica Bandage of the Shoulder (Descending). 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — The initial extremity of the roller should 
be fixed upon the arm as near as possible to the axillary line 
by one or two circular turns, and if it is applied to the right 
shoulder the bandage should be passed under the axilla and 
carried obliquely over the shoulder to the base of the neck, 
then downward across the front of the chest to the axilla of 
the opposite side; from the axilla the roller is carried over the 
back of the chest to the base of the neck so as to cross the 
first turn at this point ; it is then carried to the axilla and 
through this, then back to the neck, the turns descending 
toward the shouldei. These turns, taking the same course 
are repeated, each turn overlapping two-thirds of the pre- 



54 



REGIONAL BANDAGES. 



vious one until the shoulder is covered in and the circular 
turn around the arm is reached, at which point the extrem- 
ity is secured by a pin. (Fig. 44.) 

Use. — The spica bandages of the shoulder are employed 
to hold dressings to the shoulder, to hold compresses over 
the acromial end of the clavicle in case of dislocation of that 
portion of the bone, to retain the shoulder-cap used in the 
treatment of fractures of the upper portion of the humerus, 
and to retain dressings to the axilla. 



Figure-of-eight Bandage of the Neck and Axilla. 



Fig. 45. 



Roller Two Inches in Width, Five Yards in Length. 

Application. — The initial extremity of the roller is 
fixed upon the side of the neck and secured by one or two 

loosely applied circular turns ; 
if applied to the right axilla 
carry the bandage from left to 
right over the right shoulder 
to the posterior part of the 
axilla under which it passes, to 
ascend in front over the same 
shoulder to the back of the 
neck ; these figure-of-eight 
turns around the neck and 
axilla, each turn overlapping 
two-thirds of the previous 
turn, are repeated until the 
desired space is covered, and 
the bandage is completed by a circular turn around the 
neck. (Fig. 45.) 

Use. — This will be found a useful bandage to secure dress- 
ings to the base of the neck, the upper part of the shoulder, 
and to the axilla, as it does not restrict the motions of the 
arm unless drawn too tight. 




Figure-of-eight bandage of 
the neck and axilla. 



VELPEAU'S BANDAGE. 



55 



Velpeau's Bandage. 



Two Rollers Two and a Half Incites in Width, 
Seve7i Yards in Length. 

Application. — The patient should place the fingers of 
the hand of the affected side on the opposite shoulder ; the 
initial end of the roller should be placed on the body of the 
scapula of the sound side and secured by a turn made by 



Ftg 




Velpeau's baudage. 

earning the bandage over the shoulder of the affected side, 
near its outer portion, then conducting it downward over 
the outer and posterior surface of the arm of the same side, 
behind the point of the elbow, and obliquely across the front 
of the chest to the axilla of the opposite side, thence to the 
point of starting. This turn should be repeated, to fix the 
initial extremity of the bandage. Having completed the 
second turn, carry the roller transversely around the thorax, 
passing over the flexed elbow of the affected side, from this 
point to the axilla, and through this to the back. From this 
point the roller is carried over the shoulder and down the 



56 REGIONAL BANDAGES. 

outer and posterior surface of the arm behind the elbow and 
obliquely across the front of the chest through the axilla to the 
back, and continuing, passes transversely across the back of 
the chest to the elbow, which it encircles, then passing to the 
axilla. These alternating turns are repeated until the arm 
and forearm are bound firmly to the side and chest. The 
vertical turns over the shoulder, each turn covering in two- 
thirds of the previous turn and ascending from the point of 
the shoulder toward the neck and from the posterior surface 
of the arm toward the elbow, are applied until the point of 
the elbow is reached. The transverse turns passing around 
the chest and arm are so applied that they ascend from the 
point of the elbow toward the shoulder, each turn covering 
in one-third of the previous one, and the last turn should 
pass transversely around the shoulder and chest, covering 
the wrist. (Fig. 46.) 

The extremity of the bandage should be secured by a 
pin where it ends, and additional fixation will be secured by 
introducing a number of pins at the points where the turns 
of the bandage cross each other. 

Use. — This bandage is employed to fix the arm in the 
treatment of certain fractures of the clavicle and scapula, 
also to secure fixation of the humerus after the reduction of 
dislocations of the shoulder-joint. 

Desault's Bandage. 

Three Hollers Two and a Half Inches in Width, 
Seven Yards in Length. 

A wedge-shaped pad to fit in the axilla is also required. 
These rollers are known as the first, second and third 
rollers. 

First Roller of Desault's Bandage. 

Application. — Before applying the first roller the arm 
of the patient on the injured side should be elevated and 
carried off at right angles to the body ; the wedge-shaped 



57 

pad with its base in the axilla should next be applied to 
the side of the chest, and the initial extremity of the roller 
is placed upon the middle of the pad and fixed by tw~o or 
three circular turns around the chest ; the bandage is then 
carried obliquely across the front of the chest to the sound 



Fig. 4; 




First roller of Desault's bandage. 

shoulder and passed under the axilla, brought over the 
shoulder and conducted around the chest to pass over the 
pad, and it is next carried obliquely down to the lower 
portion of the chest to a point opposite the lower end of the 
pad ; it is now made to ascend the chest by spiral turns 
until the top of the pad is reached, where it is secured. 
(Fig. 47.) 

Second Roller of Desault's Bandage. 

Application. — The arm should be brought down against 
the side so as to press upon the pad previously applied, and 
the forearm should be flexed upon the arm and brought 
across the lower portion of the chest. The initial extremity 
of the roller is placed in the axilla of the sound side, and 
the bandage is carried around the chest and over the arm of 



58 



REGIONAL BANDAGES. 



the injured side, making a circular turn around the chest to 
fix it ; then spiral turns are made around the chest from above 
downward until the elbow is reached, the turns being more 



Fig. 48. 




Second roller of Desault's bandage. 



firmly applied as they descend, and when this point 
reached the end of the bandage is secured. (Fig. 48.) 



is 



Third Boiler of Desault's Bandage. 

Application. — The initial extremity of the roller is 
placed in the axilla of the sound side, and the bandage is 
carried obliquely over the front of the chest to the shoulder 
of the injured side, passed over this, and conducted down 
the back of the arm to the elbow, thence obliquely upward 
over the upper fifth of the forearm to the axilla of the sound 
side. From this point it is carried backward obliquely over 
the back of the chest to the shoulder ; crossing the previous 
shoulder-turn it is conducted down the front of the arm to 
the elbow, then around this and backward obliquely over 
the back of the chest to the axilla of the sound side. These 
turns are repeated until three sets of turns have been 
applied, and the turns should overlie each other exactly. 
(Fig. 49.) The course of the turns of the third roller is 



SPIRAL BANDAGE OF THE CHEST. 59 

considered the most difficult to remember, and the student 
may be assisted in its correct application by remembering 
that all the turns start at the axilla, pass to the shoulder, 
and then to the elbow, and from the elbow always return to 

Fig. 49. 




Third roller of Desault's bandage. 

the starting-point — the axilla. The turns of the third roller 
make two triangles, one on the anterior surface of the chest, 
the other upon the back. 

After the application of the three rollers the hand and un- 
covered portion of the forearm should be supported in a sling 
suspended from the neck. 

Use. — This bandage, applied completely, or some one of 
its various rollers, is employed in the treatment of fractures 
of the clavicle. 

Bandages of the Trunk. 

Spiral Bandage of the Chest. 

Holler Three Inches in Width, Nine Yards in Length. 

Application. — The initial extremity of the roller is ap- 
plied to the anterior portion of the waist, and fixed by one 
or two circular turns ; the bandage is then carried upward, 



60 



REGIONAL BANDAGES. 



encircling the chest by ascending spiral turns, each turn 
covering in one-half of the previous turn until the axillary 
line is reached; the roller is next carried around the axilla 
to the back, and obliquely over this to the base of the neck 
of the opposite side, and then it may be passed down over 
the chest and pinned to the spiral turns at several points ; a 
pin should also be inserted at the point where the last turn 
of the roller leaves the spiral turn upon the back of the chest. 
(Fig. 50.) 

Fig. 50. 




Spiral bandage of the chest. 

Use. — This bandage is employed to hold dressings to the 
chest, and may be used as a temporary dressing in fractures 
of the ribs or sternum. Care should be taken that the 
bandage be not so tightly applied as to interfere with respi- 
ration. 

Anterior Figure-of-eight Bandage of the Chest. 



Roller Two and a Half Inches in Width, Seven Yards in 

Length. 

Application. — The initial extremity of the roller should 
be placed in the axilla of one side, and fixed by two or 
three circular turns around the chest ; the bandage is then 



POSTERIOR FIGURE-OF-EIGHT BANDAGE. 61 

carried through the axilla and passed upward over the 
shoulder of the same side, and obliquely across the anterior 
portion of the chest to the axilla of the opposite side, then 
through this to the shoulder of the same side, and obliquely 
downward to the opposite axilla. These turns should be 
repeated, ascending from the shoulder toward the neck, 
each turn overlapping three-fourths of the preceding one, 
until five or six turns have been applied, the end of the 

Fig. 51. 




Anterior figure-of-eight bandage of the chest. 

bandage being secured by a pin (Fig. 51), or it may be 
completed by a circular turn around the chest. 

Use. — This bandage may be employed to bring the 
shoulders forward, and to hold dressings to the anterior 
portion of the chest. 

Posterior Figure-of-eight Bandage of the Chest. 



Roller Two and a Half Indies in Width, Seven Yards 
in Length. 

Application. — The initial extremity of the roller should 
be placed upon the outer portion of the left shoulder, and the 
bandage is carried obliquely backward and downward to the 
axilla of the opposite side ; it is then passed through this 

4 



62 REGIONAL BANDAGES. 

and conducted over the shoulder of the same side and passed 
obliquely downward to the axilla of the opposite side and 
carried through this and brought up over the shoulder to fix 
the initial extremity of the roller. These turns are repeated 
five or six times, the same precautions being observed in 

Fig. 52. 




Posterior figure-of-eight bandage of the chest. 

covering the turns and in ascending from the shoulder 
toward the neck (Fig. 52). In applying both of these ban- 
dages the crosses of the bandage, either anterior or posterior, 
should be made in the median line of the chest. 

Use. — This bandage may be employed to hold dressings 
to the posterior portion of the chest and to draw the shoul- 
ders backward. 

Suspensory and Compressor Bandage of the Breast. 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — The initial extremity of the roller should 
be placed upon the scapula of the affected side, and secured 
by two oblique turns carried over the opposite shoulder and 
conducted downward under the mamma to be covered in, 
and then carried to the axilla of the same side. Next carry 



SUSPENSORY AND COMPRESSOR BANDAGE. 63 

the roller transversely around the chest, covering in the 
lowest portion of the affected mamma. These turns should be 
repeated, the oblique turns from the axilla over the shoulder 

Fig 53. 




Suspensory and compressor bandage of the breast. 

alternating with the transverse turns around the chest until 
the breast is covered in, each series of turns ascending, 
and covering two-thirds of the preceding turn. (Fig. 53.) 

Use. — This bandage is employed to support the breast 
and to make compression at the same time ; it may also be 
employed to hold dressings to the breast. 

Suspensory and Compressor Bandage of Both 
Breasts. 



Two Rollers Two and a Half Inches in Width, Seven 
Yards in Length. 

Application. — The initial extremity of the bandage 
should be secured by oblique turns of the axilla and shoulder 
as in the preceding bandage ; the bandage should next be 
carried transversely around the back to the breast, then 
under the breast and upward over the opposite shoulder, 
then obliquely downward around the chest to the other side, 



64 



REGIONAL BANDAGES, 



being carried transversely over the lower portion of both 
breasts to the point of starting upon the back. Repeat 
these oblique turns from the shoulder to the axilla and from 
the axilla to the shoulder, and alternate these turns with a 



Fig. 54. 




Suspensory and compressor 



e of both breasts. 



transverse turn around the chest and over both breasts. 
Both series of turns should ascend, and each turn should 
overlap two-thirds of the preceding turn. (Fig. 54.) 

Use. — This bandage is employed to support and compress 
both breasts and to retain dressings to the breasts. 



SINGLE SPICA BANDAGE OF THE GROIN. 65 

Bandages of the Lower Extremity. 

Single Spica Bandage of the Groin (Ascending). 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — Place the initial extremity of the bandage 
upon the anterior portion of the right thigh just below the 
groin and secure it by one or two circular turns around the 
thigh, or place the initial extremity of the roller obliquely 
upon the upper part of the thigh and carry it behind the 

Fig. 55. 




Ascending spica bandage of the groin. 

thigh and upward around the outer side of the thigh to the 
abdomen, omitting the circular turns ; then carry the ban- 
dage obliquely across the lower part of the abdomen to a 
point just below the crest of the left ilium and conduct it 
transversely around the back of the pelvis to a correspond- 
ing point on the opposite side; then bring it obliquely 
downward to the groin over to the inner portion of the 
thigh, carrying it around the thigh, crossing the starting- 
turn in the middle line of the thigh. These turns are 



66 EEGIONAL BANDAGES. 

repeated, each turn ascending and covering in two-thirds of 
the previous turn, until six or eight complete turns have 
been made, and the bandage is secured at any point where 
it ends. (Fig. 55.) 

Single Spica Bandage of the Groin (Descending). 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — Place the initial extremity of the roller 
obliquely upon the anterior surface of the right thigh and 
secure it by one or two circular turns around the thigh, or 

Fig. 56. 




Descending spica bandage of the groin- 

start the bandage with an oblique turn, as previously de- 
scribed ; then carry the bandage obliquely across the abdo- 
men to a point just below the crest of the ilium, and conduct 
it transversely around the back of the pelvis to a correspond- 
ing point on the opposite side ; then bring it obliquely down 
over the lower portion of the abdomen, crossing the first turn, 
to the junction of the thigh with the scrotum, pass it under 
the thigh and bring it up over the lower part of the abdomen, 
and let it follow the course of the first turn. These turns 



DOUBLE SPICA BANDAGE OF THE GROINS. 67 

are repeated, each turn descending and overlapping two- 
thirds of the previous turn until the groin is covered (Fig. 56). 
When either of these bandages is applied to the left groin, 
after the initial extremity of the roller is fixed, it is carried 
first to the crest of the ilium of the same side, then around 
the back of the pelvis to a corresponding point on the oppo- 
site side, then obliquely across the lower part of the abdo- 
men to the outer aspect of the thigh, being conveyed under 
this and brought up between the thigh and the scrotum, 
passing obliquely over the groin to follow the course of the 
original turn. The turns may be made either to ascend or 
descend as the bandage is applied. 

Double Spica Bandage of the Groins. - 

Roller Three Inches in Width, Nine Yards in Length. 

Application. — The initial extremity of the roller is 
placed upon the abdomen just above the iliac crests and 

Fig. 57. 




Double spica bandage of the groins. 

secured by one or two circular turns ; the bandage is then 
carried from a point just below the crest of the right ilium 



68 REGIONAL BANDAGES. 

obliquely across the lower portion of the abdomen to the 
outer portion of the thigh, and is carried around this and 
brought up between the scrotum and the thigh, and is passed 
obliquely over the groin, crossing the previous turn in the 
median line, and is conducted to a point just below the crest 
of the ilium on the same side. The bandage is then con- 
tinued around the pelvis to the same point on the opposite 
side, and from this point is made to pass obliquely over the 
groin to the inner side of the thigh, passing around this and 
coming up on its outer side, crossing the previous turn at 
the middle line of the groin, to be carried obliquely across 
the groin and lower part of the abdomen to the crest of the 
ilium on the opposite side. These turns are repeated, each 
turn covering in two-thirds of the previous turn, until both 
groins have been covered (Fig. 57). The turns may be so 
applied as to ascend or descend, forming the ascending or 
descending double spica bandage of the groin. When 
properly applied, this bandage presents three sets of cross- 
ing turns, one in each groin and one in the median line of 
the abdomen. 

Use. — The spica bandages of the groin, either single or 
double, are employed to hold dressings to wounds in the 
inguinal region — for instance, those resulting from herni- 
otomy, or from operation upon the glands of the groin. 
They are also employed to make pressure upon this region, 
and will often prove of use in the securing of compresses 
applied for the temporary retention of hernise. 



Figure-of-eight Bandage of the Knee. 

Roller Two and a Half Inches in Width, Five Yards in 

Length. 

Application. — The initial extremity of the roller is 
placed upon the thigh three inches above the patella and 
secured by two or three circular turns; then conduct the 
bandage over the outer condyle of the femur across the pop- 
liteal space to the inner border of the tibia and around the 



FIGURE-OF-EIGHT BANDAGE OF KNEE. 69 

anterior surface below the tubercle and head of the fibula 
and make one circular turn ; the roller should then be car- 
ried obliquely across the popliteal space to the inner condyle 
of the femur, crossing the previous turn ; then carry it around 
the front of the thigh to the outer condyle ; repeat these 

Fig 58. 




Figure-of-eight bandage of the knee. 

turns, ascending toward the knee from the leg and descend- 
ing from the thigh toward the knee, and finish the bandage 
by a circular turn over the patella (Fig. 58). 

Use. — This bandage is employed to hold dressings to the 
knee-joint either anteriorly or posteriorly. These figure-of- 
eight turns are often employed in covering the knee in 
applying the spiral reversed bandage of the lower ex- 
tremity when it is desired that the patient be allowed to 
bend the knee. 

Fi<tURe-of-eight Bandage of Both Knees. 

Roller Two and a Half Inches in Width, Seven Yards in 

Length. 

Application. — Place the knees of the patient together 
with a compress between them ; then place the initial ex- 
tremity of the roller upon one thigh, about three inches 

4* 



70 REGIONAL BANDAGES. 

above the patella, and secure it by one or two circular turns 
around both thighs ; then conduct the roller from the outer 
condyle of the femur obliquely across the popliteal spaces 
of both legs to the head of the fibula on the opposite side, 

Fig. 59. 




Figure-of-eight bandage of both knees. 

making a circular turn around both legs ; pass the roller 
from the head of the fibula on the opposite side across the 
popliteal space to the external condyle opposite the point of 
starting. 

Repeat these turns, descending from the thighs and ascend- 
ing from the legs, until the knees are covered, and finish the 
bandage by carrying a turn of the bandage at right angles 
to the previous turns between the thighs and the legs. 
(Fig. 58.) 

Use. — This bandage is employed to secure fixation of 
the limbs after operation upon the perineum, and may also 
be employed to obtain temporary fixation of the limbs in 
transporting cases of fracture of the neck of the femur, 
and after the reduction of dislocations of the head of the 
femur. 



spica bandage of the foot. 71 

Spica Bandage of the Foot. 

Roller Two and a Half Inches in Width, Five Yards in 

Length. 

Application. — Fix the initial extremity of the roller 
upon the ankle and secure it by two circular turns ; then 
carry the bandage obliquely over the dorsum of the foot to 
the metatarso-phalangeal articulation and make a circular 
turn around the foot at this point ; then continue it upward 
over the metatarsus by making two or three spiral reversed 
turns ; next carry the bandage parallel with the inner or 
outer margin of the sole of the foot, according to whether 
it is applied to the right or left foot, directly across the pos- 
terior surface of the heel ; thence along the opposite border 

Fig. 60. 




Spica bandage of the foot. 

of the foot and over the dorsum, crossing the original turn 
in the median line of the foot. This completes the first 
spica turn. These spica turns are repeated, gradually 
ascending by allowing each turn to cover in three-fourths 
of the preceding turn, until the foot is covered in with the 
exception of the posterior portion of the sole of the heel. 
(Fig. 60.) Care should be taken to see that the turns cross 



72 REGIONAL BANDAGES. 

each other in the median line of the foot, and that the turns 
are kept parallel to each other throughout their course. 

Use. — This bandage will be found very useful when it is 
desired to make firm compression upon the foot or to retain 
dressings to it ; it is especially useful in the treatment of 
sprains of the ankle or anterior tarsus. 

Bandage of Foot Covering the Heel (American). 

Roller Two and a Half Inches in Width, Seven Yards in 

Length. 

Application. — The initial extremity of the roller is 
placed upon the leg just above the malleoli and fixed by two 
circular turns around the leg ; the bandage is then carried 
obliquely across the dorsum of the foot to the metatarso- 
phalangeal articulation, at which point a circular turn is 
made ; two or three spiral or spiral reversed turns are then 
made ascending the foot ; the roller is next carried directly 

Fig. 61. 




Bandage of foot covering the heel. 

over the point of the heel and continued back to the dorsum 
of the foot ; thence beneath the instep around one side of 
the heel and up over the instep ; from this point it is car- 



BANDAGE OF FOOT NOT COVERING HEEL. 73 

ried beneath the instep around the other side of the heel 
and up in front of the ankle, from which point it may be 
continued up the leg. (Fig. 61.) 

Use. — This bandage is employed to cover in the foot and 
retain dressings to the foot and heel. 

Bandage of Foot not Covering the Heel (French). 

Roller Tivo and a Half Inches in Width, Seven Yards 
in Length. 

Application. — Fix the initial extremity of the roller 
upon the leg just above the malleoli and secure it by two 
circular turns around the leg ; the bandage is then carried 
obliquely across the dorsum of the foot to the metatarso- 
phalangeal articulation and at this point a circular turn 

Fig. 62. 




Bandage of foot not covering the heel. 

around the foot is made. The roller is now carried up the 
foot, covering it in with two or three spiral reversed turns, 
and at this point a figure-of-eight turn is made around the 
ankle and instep; this should be repeated once, which will 
cover in the foot with the exception of the heel ; the ban- 
dage may then be continued up the leg with spiral reversed 
turns. (Fig. 62.) 



74 KEGIONAL BANDAGES 

Use. — This bandage may be employed to secure dressings 
to the foot and is the one generally used to cover the foot in 
applying the spiral reversed bandage of the lower extremity. 

Spiral Eeversed Bandage of the Lower Extremity. 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — The initial extremity of the roller is 
placed upon the leg just above the malleoli and secured by 
two circular turns, then carried obliquely over the foot to 
the metatarso- phalangeal articulation and here a circular 
turn is made around the foot ; the foot is next covered in with 
two or three spiral reversed turns and two figure-of-eight 
turns of the ankle and instep, and just above the ankle one 
or two circular or spiral turns are made around the leg, and 
as the bandage is carried up the leg, as it increases in diam- 
eter, spiral reversed turns are made until it approaches the 
knee ; at this point, if the limb is to be kept straight, the 
spiral reversed turns may be continued over this region and 

Fig. 63. 




Spiral reversed bandage of the lower extremity. 

up upon the thigh. If the knee is to be bent, figure-of- 
eight turns may be applied until the knee is covered, and 
then the thigh may be covered with spiral reversed turns. 
(Fig. 63.) To cover in the thigh as well as the leg, two 
bandages of the dimensions before given will be required. 



FIGURE-OF-EIGHT BANDAGE OF THE LEG. 75 

Care should be taken to keep the reverses in a line and not 
to make them over the spine of the tibia, as they may thus 
become painful to the patient. 

Use. — This is one of the most frequently employed of the 
roller bandages ; it is used to apply pressure to the lower ex- 
tremity, to retain dressings, and to secure splints in the treat- 
ment of fractures and dislocations. 

FiGURE-OF-EIGHT BAXDAGE OF THE LEG. 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Applicatiox. — This bandage differs from the spiral re- 
versed bandage of the lower extremity only in the fact that 

Fig. 64. 




Figure-of-eight bandage of the leg. 

when the swell of the calf is reached, figure-of-eight turns 
are made around the leg instead of spiral reversed turns. 
In applying the roller, when the calf of the leg is reached, 



76 SPECIAL BANDAGES. 

the bandage is carried obliquely around the leg and brought 
in front of the leg and made to cross the starting- turn in 
the median line ; these turns are repeated until the calf of 
the leg has been covered in, and the bandage is finished with 
one or two circular turns just below the knee. (Fig. 64.) 

Use. — This bandage holds its place more firmly than the 
ordinary spiral reversed bandage of the leg, and may be 
employed in the treatment of ulcers of the leg in conjunction 
with strapping, where it is desirable to change the dressings 
at infrequent intervals and to allow the patient to walk about 
during the course of treatment. 



SPECIAL BANDAGES. 

Spiral Reversed Bandage of the Penis. 

Roller Three-quarters of an Inch in Width, Thirty Inches 
in Length. 

Application. — Fix the initial extremity of the roller by 
two circular turns around the penis close to the pubis; then 

Fig. 65. 




ral reversed bandage of the penis. 



RECURRENT BANDAGE OF STUMP. 



77 



carry the bandage obliquely down to the corona glandis ; 
from this point ascend the body of the penis by spiral re- 
versed turns to the pubis and finish the bandage by two 
figure-of-eight turns around the neck of the scrotum and 
root of the penis ; split the end of the bandage so as to form 
two tails and secure it by tying these around the root of 
the penis. (Fig. 65.) 

Recurrent Bandage of Stump. 

Roller Two and a Half Indies in Width, Five to Seven 
Yards in Length. 

Application. — Place the initial extremity of the roller 
upon the anterior or posterior surface of the limb a few 
inches above the extremity of the stump, and carry the 



Fig. 66. 




Recurrent bandage of stump. 

bandage to the end of the stump, and then conduct it 
upward or downward on the limb, as the case may be, to a 
point directly opposite to the point of starting ; then bring 
the bandage back over the face of the stump to the point 
of starting and continue these recurrent* turns, each turn 
overlapping two-thirds of the previous one, until the face 



78 SPECIAL BANDAGES. 

of the stump is covered ; then reverse the bandage and 
secure the recurrent turns at their points of origin by two 
or three circular turns. The roller should next be carried 
obliquely down to the end of the stump and a circular turn 
should be made around this, and the bandage should next 
be carried up the limb by spiral or spiral reversed turns 
beyond the point at which the recurrent turns terminated, 
and secured by one or two circular turns. (Fig. 66.) 

In applying this bandage in very short stumps resulting 
from amputations at or near the shoulder or hip-joints, after 
making the recurrent and spiral turns, it will be found 
necessary to carry the bandage, in the case of the shoulder, 
across the chest to the opposite axilla and back, and apply 
several of these turns ; so in case of the hip amputations it 
will be found best to finish the bandage with a few turns 
about the pelvis. 

Bandage for Securing the Hands and Feet in 
the Lithotomy Position. 

Holler Two and a Half Inches in Width, Three Yards in 

Length. 

Application. — The hand of the patient should be brought 
down and made to grasp the outer side of the foot ; the 
initial extremity of the roller is fixed by two circular turns 
around the wrist and ankle, and the bandage is then passed 
around the foot and hand, and these turns are alternated 
with turns around the wrist and ankle, until the hand and 
foot are firmly secured. The same procedure is adopted 
with the hand and foot of the opposite side. (Fig. 67.) 

Use. — This bandage is useful in securing the hands and 
feet while the patient is put in the lithotomy position for 
that operation, or for perineal section. 

Liebreich's Eye Bandage. 

This bandage consists of a strip of flannel two and a half 
inches in width and from six to ten inches in length, to the 



BANDAGE OF SCULTETUS. 



79 



extremities of which are sewed tapes. It may be applied 
transversely so as to cover both eyes, or obliquely so as to 
cover one eye only, and is secured by the tapes carried 
around the head and tied over the forehead. (Fig. 68.) 



Fig. 6< 



Fig. 





Bandage for securing hands and 
feet for lithotomy. 



Liebreich's eye bandage. 



Use.— This bandage is used to hold compresses or dress- 
ings to the eye or eyes, and the elasticity of the flannel 
permits of its being applied so as to make a variable 
amount of pressure. 

Bandage of Scultetus. 



This is a compound bandage, consisting of a number of 
pieces of muslin, and may be prepared from a two and a 
half or three-inch roller by cutting off strips long enough 
to encircle the part about one and one- third times. These 
strips are placed under the part in such a manner that the 
first piece shall be overlapped by the second, the second by 
the third, and so on from below upward ; the pieces are 
then brought around the limb, and the extremities of the 



80 



SPECIAL BANDAGES. 



last piece are secured by pins. (Fig. 69.) This bandage 
was formerly much employed in the treatment of compound 
fractures to secure dressings to the wound, and possessed 
the advantage that single strips which became soiled could 
be removed without disturbing the whole dressing, the new 
strip to be introduced being pinned to the extremity of the 

Fig. 69. 



_M "C 




Bandage of Scultetus. 

soiled piece to be removed, and then being drawn through 
by its removal. This bandage will often be found conve- 
nient in applying dressings to cases of excision of the joints, 
where as little disturbance of the parts as possible is im- 
portant in dressing the wounds. When the strips are 
attached to each other by a thread passed through each 
strip in the centre, the bandage is known as Pott's bandage. 



THE RUBBER BANDAGE 



81 



This bandage is applied and secured in the same manner, 
but it possesses no advantages over the bandage of Scul- 
tetus. 

The Rubber Bandage. 



This bandage is made from a strip of rubber sheeting, 
from one inch to four inches in width and from three to five 
yards in length, which, for convenience of application, is 
rolled into a cylinder. 

Its use was introduced to the profession by Dr. Martin, 
of Boston, and it will be found a useful form of dressing 
where it is considered desirable to apply elastic pressure to 
a part. 

It may be employed in the treatment of varicose veins of 
the legs, in chronic ulcers of those parts where pressure is 

Fig. 70. 




Martin's rubber bandasre. 



an important element in the treatment, and may be used as 
a substitute for strapping to secure this object. Its appli- 
cation has also been recommended in the treatment of 
swelled testicle in that stage of the affection in which press- 
ure is indicated. 

Application. — For application to the leg a rubber ban- 
dage two and a half inches in width and three yards in 
length is required. 

The initial extremity of the roller is fixed upon the foot 
near the toes and secured by a circular turn ; the foot is 
then covered in by spiral turns overlapping each other about 
two-thirds, and a figure-of-eight turn is made from the ankle 



82 SPECIAL BANDAGES. 

to the instep, and the bandage is then carried up the limb 
to the knee with spiral turns, where it is secured by two 
tapes sewed to the terminal extremity of the bandage, which 
are passed around the leg and tied. The bandage need not 
be reversed, as its elasticity allows it to conform to the shape 
of the limb. Care should be taken not to apply these turns 
with too much firmness ; the bandage should be stretched 
very slightly ; if this precaution is not taken, it soon be- 
comes uncomfortable to the patient. A patient using one 
of these bandages will soon learn to apply it himself, making 
just the requisite amount of tension to secure its holding its 
place and to insure a comfortable amount of pressure upon 
the part. A well-fitting stocking may be placed upon the 
limb before the bandage is applied, or it may be applied 
directly to the skin. 

The bandage should be removed at night when the patient 
goes to bed and hung up to dry, as its inner surface becomes 
moist from the secretions from the skin; it should be re- 
applied as soon as the patient rises in the morning. 

In using it in the treatment of ulcers of the leg no oint- 
ments should be applied to the ulcer, as oily dressings soon 
destroy the rubber ; dressings may be made to the ulcer by 
means of dry powders, such as oxide of zinc, iodoform, or 
aristol, before the bandage is applied. 

In the treatment of swelled testicle the bandage is applied 
to the testicle by means of recurrent turns not too firmly 
made, and secured in place by spiral turns, until the whole 
surface of the organ is covered in ; the end of the bandage 
is secured with tapes tied around the root of the scrotum. 
The same precaution to apply the bandage so as to make 
only moderate pressure should here also be observed. 

Fixed Dressings or Hardening Bandages. 

For the application of these dressings a variety of sub- 
stances are used which are incorporated in the meshes of 
some fabric, such as crinoline or cheese-cloth, or painted 
over its surface to give fixity or solidity to the bandage. 

The materials most commonly used in the preparation of 



THE PLASTER-OF-PARIS BANDAGE. 83 

fixed dressings are plaster-of-Paris, starch, silicate of sodium 
or potassium, paraffine, or a mixture of chalk and gum or 
of oxide of zinc and glue. 



The Plaster-of-Paris Bandage. 

The plaster-of-Paris used for the application of surgical 
dressings should be of the same quality as that which the 
dental surgeons employ in taking casts for teeth — that is, 
the extra-calcined variety. If moist or of inferior quality, 
it will not set rapidly or firmly, and will fail to give sufficient 
fixation to the dressing. 

The plaster-of-Paris dressing may be applied in several 
ways, either by covering the part to be enclosed with some 
loose fabric, and rubbing the moist plaster into it, alter- 
nating the layers of the fabric with layers of moist plaster, 
or it may be applied by means of a roller which has been 
prepared with plaster-of-Paris and is moistened and applied 
to the part. 

To apply a plaster-of-Paris dressing according to the 
first method, the part to be enclosed — the leg, for instance 
— should first be covered by a neatly applied flannel ban- 
dage or a muslin bandage, which has been shrunken by 
being washed ; new muslin is not satisfactory as a primary 
application to a limb in applying a plaster-of-Paris dressing, 
as the moisture from the plaster wets it and causes it to 
shrink, so that it may exert injurious pressure after the 
bandage becomes dry. 

The limb having been covered by the bandage, and any 
bony prominences such as the malleoli having been padded 
with small wads of cotton to prevent undue pressure upon 
them, the part is next covered by a layer of turns of a crino- 
line bandage or by strips of cheese-cloth or any other loose 
material. A small quantity of plaster-of-Paris is next 
mixed with water until it has the consistence of thick cream, 
when it is smeared evenly over the whole surface of the 
previously applied bandage. Another layer of the bandage 
or of strips is next applied, and the plaster is smeared over 



84 SPECIAL BANDAGES. 

this in the same manner, and so alternate layers of plaster- 
of-Paris and bandage are applied until a casing of the de- 
sired thickness is obtained. If the plaster-of-Paris of the 
quality previously described be used, it will set or become 
hard in a few minutes. 

The most convenient method of applying the plaster-of- 
Paris dressing is that employed by Prof. Sayre, which con- 
sists in the use of bandages which have been previously 
prepared with plaster-of-Paris ; these are moistened and 
applied while moist to the part to be encased. 

Preparation of the Plaster-of-Paris Bandage. 

These bandages are prepared by taking cheese-cloth, mos- 
quito-netting, or crinoline, which latter is by far the best 
fabric, and cutting or tearing it into strips two and a half 
to three inches in width and five yards in length. These 
are laid on a table, and plaster-of-Paris of the quality 
before mentioned is dusted over them and rubbed into the 
meshes of the fabric ; the material when impregnated with 
plaster is loosely rolled into a cylinder, and these bandages 
when prepared should be placed in air-tight jars or tin cans 
until required. 

Bandages thus prepared, which have been exposed to the 
air or have been kept for a long time, are not apt to set 
well when applied ; but if such bandages are placed in a 
hot oven and baked for half an hour before being used, 
they will be found to set as satisfactorily as those freshly 
prepared. 

These bandages may be prepared by a machine made for 
this purpose, but I do not think that they are apt to have 
the plaster as evenly distributed through them, and there- 
fore are not as satisfactory, as those prepared by hand. 

Application of the Plaster-of-Paris Bandage. 

Before applying this dressing, the part to be encased — 
the leg, for instance — should be covered by a flannel roller, 



PLASTER-OF-PARIS BANDAGE. 85 

the bony prominences being protected by pads of cotton, or 
a closely fitting stocking may be applied to the part. 

The bandage should be dipped in warm water and kept 
covered by water for a few moments ; it may be squeezed 
with the hand, and as soon as bubbles of air cease to escape 
it is a sign that it is thoroughly soaked and is ready for 
application. 

On removing it from the water the excess of water should 
be squeezed out by the hand and the bandage should then 
be evenly applied to the limb with just enough firmness to 
make it fit the part nicely, and as few reverses as possible 
should be made. A sufficient number of bandages are 
applied to make a dressing as firm as may be required ; 
three rollers of the above dimensions are usually quite 
ample for a dressing for the leg, and when the last roller 
has been applied some dry plaster should be moistened with 
water until it has the consistence of thick cream, and it 
should be rubbed evenly over the surface of the bandage to 
give it a finish (Fig. 71). If a good quality of plaster has 

Fig. 71. 




Leg encased in plaster-of- Paris dressing. 

been used, the bandage should be quite firm in from ten to 
fifteen minutes, but the patient should not for a few hours 
be allowed to put any weight upon the bandage. 

An equally firm bandage may be applied with the use of 
a less number of bandages, if the surgeon rubs over the 
surface of each layer of bandage applied a little moist plaster, 
then applying another layer and repeating the same pro- 
cedure ; finishing the dressing by an external coating of 
moist plaster, as above described. 



86 



SPECIAL BANDAGES. 



In applying these dressings a fewer number of bandages 
will be required if narrow strips of tin, zinc, or binder's 
board are incorporated in the layers of the bandage, which 
also increase the strength of the dressing. 

Interrupted Plaster-of-Paris Dressing. 

This form of plaster-of-Paris dressing is applied by first 
placing a short iron rod under the extremity some distance 
above and below the point at which the dressing is to be 
interrupted ; this is fixed by a few turns of the plaster 
bandage above and below the portion of the limb which is 
to be left exposed; stout wire is next bent into loops, the 

Fig. 72 




Interrupted plaster-of-Paris dressing. 

extremities of which are incorporated in the subsequent 
turns of the plaster bandage ; three loops thus placed in 
addition to the posterior iron bar will usually make the 
dressing sufficiently firm (Fig. 72). A number of turns of 
the bandage are applied to firmly fix the loops, and the 
limb is held in the desired position until the plaster has set. 

Application of the Plaster-of-Paris Jacket. 



The patient's body should be covered with a soft, closely 
fitting woven shirt without arms, but with shoulder-straps to 
hold it*in position, or an ordinary woven undershirt may be 



PLASTER-OF-PARIS JACKET. 



87 



employed ; one or two folded towels, or a pad of cotton 
folded in a towel, are next placed over the abdomen between 
the shirt and the skin — this is called, by Prof. Sayre, the 
dinner pad, and is intended to leave space for the distention 
of the abdomen after eating. Small pads of raw cotton may 



Fig. 73. 




Suspensory apparatus. 



also be placed over the anterior iliac spines, and, in the case 
of females, a pad of cotton wrapped in a handkerchief may 
be placed over each mammary gland. 

The patient should next be suspended by the apparatus 
consisting of a collar and arm-pieces attached to a cross-bar 
(Fig. 73), which is attached by a cord and pulley to a tripod. 
If this apparatus is not at hand, a very satisfactory substitute 



88 



SPECIAL BANDAGES. 



may be made by folding two towels into cravats and tying 
together the ends, so as to make two loops, one of which is 
placed in each axilla ; a bar of wood two and a half feet in 
length is next taken and the loops are secured to the ends 
of this by stout cords or handkerchiefs ; a Barton's bandage 



Fig. 74. 




Patient suspended for application of plaster jacket. 

is next applied to the head, and a strip of bandage is passed 
under the turns which cross the vertex and is secured to the 
middle of the cross-bar. The bar is next suspended by a 
cord passed through a pulley or ring which may be attached 
to the sill of a door if the ordinary tripod is not to be 
obtained. 

The patient should be slowly raised by the apparatus 



APPLICATION OF THE JURY-MAST. 89 

until the toes only are in contact with the floor, and the 
extension should not be carried to the point which makes it 
uncomfortable to the patient. (Fig. 74.) The shirt should 
be drawn downward over the hips by an assistant and held 
in place until a few turns of the bandage have been ap- 
plied. 

The plaster bandage having been soaked and squeezed, a 
turn should be made around the body above the pelvis, and 
it should then be carried downward below the iliac spines, 
and from this point should be made to ascend gradually by 
spiral turns until it reaches the axillary line. The turns 
should be applied smoothly and not too tightly. After one 
or two layers of turns have been applied, the surgeon may 
rub some moist plaster upon their surface if he desires to 
use fewer bandages. These turns are repeated until a ban- 
dage of the desired thickness is applied, and the surface of 
the dressing may be finished by rubbing it over with moist- 
ened plaster. This jacket for a child will generally require 
the use of four bandages of the dimensions given ; for an 
adult, six to eight bandages. 

The patient should be kept suspended until the bandage 
has set, usually from ten to fifteen minutes, and then should 
be carefully lifted so as not to bend the spine, and placed 
upon his back upon a mattress, until the dressing becomes 
perfectly hardened. The dinner pad, and mammary pads, 
if they have been used, should next be removed. In ap- 
plying this dressing, strips of zinc or tin may be placed 
between the layers of bandage if it is desired to give more 
strength to the dressing. 

Application of the Jury-mast by Means of Plaster- 
of-Paris. 

In disease of the spine involving the cervical or upper 
dorsal region the ordinary plaster-of-Paris jacket is not 
satisfactory, and in such cases the "jury-mast" is employed 
in connection with the plaster jacket. In applying the 
"jury-mast" the same steps are taken in the preparation of 



90 



SPECIAL BANDAGES 



the patient as in applying the plaster-of-Paris jacket, with 
the exception of extension, which need not be used. 

After three or four layers of the plaster bandage have 
been applied to the body, an apparatus made of two bars 
of metal having two perforated strips of zinc attached to 
them a few inches apart, which 
Fig. 75. partly encircle the body, is applied 

and held in position by turns of the 
plaster bandage. The perpendicu- 
lar bars have at their upper part a 
slot, into which the lower end 
(Fig. 75) of the "jury-mast" fits, 
and is secured by a screw ; to the 
upper part of this is attached a 
movable cross-bar, to which are fas- 
tened the straps of the collar from 
which the head is suspended. 

The Bavarian Dressing. 

To apply this dressing, which is 
sometimes employed in the treat- 
ment of fractures, take two pieces 
of Canton flannel the length of the 
part to be enclosed, and more than 
wide enough to envelope its cir- 
cumference. In applying it to the 
leg these pieces should be cut so as 
to r correspond to the outline of the leg and posterior portion 
of the foot. 

These pieces should be placed one over the other and 
sewed together in the middle line, the seam corresponding 
to the back of the leg. The leg and foot are then placed 
upon this, and the inner layer of flannel is brought up in 
front of the leg and over the dorsum of the foot and made 
fast with pins. (Fig. 76.) Plaster-of-Paris is next mixed 
with water and made into a paste, which is rubbed thickly 
and evenly over the flannel next to the limb until a sufficient 
thickness is obtained ; the outer layer of flannel is then 




Head-support and jury-mast. 



MOULDED PLASTER SPLINTS. 91 

brought up about the leg and moulded to its surface by the 
hands. A loosely applied roller may now be used to hold 
the dressing in place until the plaster has set. 

Fig. 76. 




Bavarian dressing. 

AVhen it is necessary to inspect the parts, the turns of the 
roller are cut, and upon separating the layers of flannel the 
two halves can be turned aside, the seam at the back acting 
as a hinge. Upon reapplying the splints to the leg they 
may be retained in position by a roller or by one or two 
strips of bandage. 

Moulded Plaster Splints. 

It is sometimes found difficult to apply the ordinary plaster 
dressings to parts irregular in their shape, and at the same 
time to have a splint which can be removed with ease. 
To accomplish this purpose moulded splints of plaster may 
be made by cutting a paper pattern of the part to be covered 
in, and then cutting pieces of crinoline to conform to this 
pattern ; eight or ten pieces will usually form a splint of 
sufficient thickness. One of these pieces of crinoline is laid 
upon a table and dry plaster is rubbed into its meshes ; 
another is laid upon this and plaster is applied to it in the 
same way, and so on until all the pieces have been placed 
in position, one over the other, with plaster rubbed well into 
the meshes. The dressing is then folded up and dipped into 
water, squeezed out, and moulded to the part and held in 
position, until it sets, by the turns of a bandage. The edges 
should overlap slightly, and in applying it a strip of waxed 
paper may be placed under the overlapping edge to prevent 



92 



SPECIAL BANDAGES. 



its adhesion to the dressing below, and thus facilitate its re- 
moval. Splints prepared in this way can be removed with 
ease, and are often of service in cases where it is desirable 
to inspect the parts frequently ; I have employed with ad- 
vantage such splints in making fixation of the hip-joint in 
cases of coxalgia, and also for the same purpose in affections 
of other joints. The splints upon being reapplied are 
secured by a few strips of bandage, or by a roller bandage. 

Trapping Plaster Bandages. 

In applying the plaster-of- Paris dressing to a part where 
there is a wound which is covered by the plaster bandage, 
it is well to make some provision whereby the plaster dress- 



Fig. 1H. 




Plaster-of- Paris bandage trapped. (Esmakch.) 

ing over the site of the wound may be cut away, making a 
trap or window through which the wound may be inspected 
or dressed, if necessary. (Fig. 77.) To accomplish this, be- 
fore applying the plaster bandage, a compress of lint or gauze 
should be placed over the wound, which, when the dress- 
ing is completed, forms a projection on its surface, indicating 
the position of the wound, and also allows the surgeon to 
cut away the dressing without injuring the skin below. 
These traps may be cut out after the bandage has par- 
tially set, or after it has become hard. In applying the 
plaster-of-Paris dressing in cases of compound fracture and 



REMOVING PLASTER-OF-PARIS BANDAGE. 93 

after osteotomy, I always make provision for trapping of the 
bandage if it should become necessary, although in the vast 
majority of cases it does not have to be done. 

Removing Plaster-of-Paris from the Hands. 

One objection to the use of plaster-of- Paris dressings is 
the difficulty of removing it from the hands of the surgeon, 
and the harsh condition in which the skin of the hands is 
left after its removal. If, however, the hands are washed 
in a solution of carbonate of sodium — a tablespoonful to a 
basin of water — the plaster w r ill be readily removed and the 
skin will be left in a soft and comfortable condition. 

Removing the Plaster-of-Paris Bandage. 

The removal of the plaster bandage is sometimes a matter 
of difficulty, particularly if it has to be removed before the 
parts below it are consolidated, as it may disarrange them 
and cause the patient pain if it is not accomplished without 
much force. 

When the bandage is applied to get a cast of the part, a 
strip of sheet-lead one inch in width is first placed over the 
flannel bandage, and is allowed to project at each end beyond 
the dressing ; the plaster can then be readily cut through upon 
this strip with a knife without injury to the parts below. 

It may also be removed by means of a saw devised for 
this purpose (Fig. 78), or by strong cutting shears of various 

Fig. 78. 




Hunter's saw for removing plaster bandages. 

kinds (Fig. 79) ; or a line may be painted over the dressing 
with hydrochloric acid or vinegar, which softens the plaster so 
that it can readily be cut through with a knife. Dr. William 

5* 



94 SPECIAL BANDAGES. 

B. Hopkins has devised a verteb rated metal chain which is 
applied to the part before the plaster is applied and removed 
when the bandage has set, leaving a hollow longitudinal 




Shears for cutting plaster bandages. 

ridge which can be cut through or divided with a rasp. The 
saw is, I think, the most satisfactory means of removing 
these dressings ; the only caution to be exercised is to use it 
carefully, as the final layers of the bandage are divided, to 
avoid wounding the skin. 

Uses of Plaster-of-Paris Dressings. 

These dressings are employed to secure fixation, as pri- 
mary or secondary dressings in the treatment of fractures, 
and for a like purpose in injuries and diseases of the joints. 
They are also largely used in the treatment of diseases and 
deformities of the spinal column, and will also be found most 
satisfactory applications after osteotomy and tenotomy, to 
secure immobility and hold the parts in their corrected posi- 
tions ; when employed in dressing cases after tenotomy, they 
are generally used for a few weeks until the proper mechani- 
cal apparatus is applied. 

The Starched Bandage. 

To apply this bandage starch is first mixed with cold water 
until a thick creamy mixture results; to this is added boiling 
water until a clear mucilaginous liquid is produced ; if too 
thin it can be made thicker by heating it upon a stove. The 



SILICATE OF POTASSIUM BANDAGE. 95 

part to be dressed is first covered with a flannel roller, and 
over this a few layers of a cheese-cloth or crinoline bandage, 
which has been shrunken, are applied ; the starch is then 
smeared or rubbed with the hand evenly into the meshes of 
the material, and the part is again covered with a layer of 
turns of the bandage, and the starch is again applied ; this 
manipulation is continued until a dressing of the desired 
thickness is produced. Strips of pasteboard may be applied 
between the lavers of the bandage to give additional strength 
to the dressing, if desired. 

It requires from twenty-four to thirty- six hours for the 
starched bandage to become dry and thoroughly set, and it 
may be removed in the same way in which the plaster-of- 
Paris dressing is removed. 

Use, — Before the introduction of the plaster- of-Paris 
dressing it was formerly much employed in the treatment of 
fractures and in injuries of the joints. It may be used in 
such cases, but possesses no advantage over the former dress- 
ing and has the disadvantage of setting much less promptly. 

Gum and Chalk Bandage. 

In applying this dressing equal parts of powdered gum 
arabic and precipitated chalk are mixed with boiling water 
until a mass of the consistence of cream results. This is 
applied to the cheese cloth or crinoline bandage in the same 
manner as is the starch in the application of the starched 
bandage; it has tre advantage over the latter dressing of 
setting more promptly, five or six hours only being required 
for it to become hard. It may be employed for the same 
purposes as the starched or plaster-of-Paris bandage. 

Silicate of Potassium or Sodium Bandage. 

In applying this bandage after a flannel roller and several 
layers of a cheese-cloth or crinoline bandage have been ap- 
plied to the part, the surface of the latter is coated with 
silicate of sodium or potassium applied by means of a brush, 



96 SPECIAL BANDAGES. 

then a second layer of bandage is applied and treated in the 
same manner, and this manipulation is continued until a 
bandage of the desired thickness is produced. It requires 
twenty-four hours for this dressing to become firm. In 
removing the silicate bandage it may be first softened by 
soaking it in warm water and then it can be readily cut with 
scissors. 

In applying either the starched bandage or the silicate of 
potassium bandage care should be taken to use cheese-cloth 
or crinoline which has been shrunken by being moistened 
and allowed to dry before being employed ; otherwise dan- 
gerous compression of the part may occur if the bandage 
has been firmly applied and shrinks after its application. 

The Paraffine Bandage. 

Paraffine, which melts at from 105° to 120° F., is used in 
the application of this bandage. The limb being covered 
by a flannel roller, a vessel containing paraffine is placed in 
a basin of boiling water. As the roller, which may be either 
of flannel, cheese-cloth, or crinoline, is unwound it is passed 
through the melted paraffine and applied to the part, and 
the turns are repeated until a dressing of sufficient thickness 
results, and the surface may be brushed over with melted 
paraffine. This dressing sets very rapidly, being quite firm 
in from five to ten minutes. 

It possesses the advantage of the other fixed dressings in 
that it does not absorb discharges and become offensive, and 
for this reason it was formerly recommended in the treat- 
ment of compound fractures. 



Glue or Glue and Oxide of Zinc Bandage. 

Glue or glue combined with oxide of zinc has been em- 
ployed in the preparation of fixed dressings, but possesses 
no advantages over those previously mentioned. 



RAW-HIDE OR LEATHER SPLINTS. 



97 



Raw-hide or Leather Splints or Dressings. 

In moulding raw-hide or leather splints it is necessary, 
first, to apply a plaster-of-Paris bandage to the part to which 
the raw-hide splint is to be fitted ; as soon as the plaster has 
set it is removed, and a solid plaster cast is next made by 
pouring liquid plaster-of-Paris into this mould. When this 
has become dry a piece of raw-hide, which has been soaked 
for a time in warm water, is moulded to the cast and held 
firmly in contact with it by a bandage until it has become 
perfectly dry. It is then removed, and its surface is cov- 
ered with several coats of shellac, to prevent its absorbing 
moisture from the skin when applied, and changing its shape. 
Eyelets or hooks are fastened to the edges of the splint, 
through which strings are passed to 
secure the splint in place. 

Made in this manner raw-hide 
splints fit the part very accurately, 
and constitute a very satisfactory 
dressing for cases of joint-disease, 
and in the form of leather jackets 
are often employed in the treatment 
of disease of the spine in place of the 
plaster-of-Paris jacket. (Fig. 80.) 
In the treatment of high dorsal 

Fig. 81. 



Fig. 80. 





Leather jacket with juiy- 
mast. 



Leather splint for cervical caries 
(Owen.) 



98 SPECIAL BANDAGES. 

or cervical caries a leather splint in two sections, which rests 
upon the shoulders and supports the head, is often used 
with good results. (Fig. 81.) 

Binder's Board or Pasteboard Splints. 

This material, which can be obtained in sheets of different 
thickness, is frequently employed for the manufacture of 
splints. In moulding these splints a portion of the board 
of the requisite size and thickness is dipped in boiling 
water for a short time, and when it has become softened it 
is removed and allowed to cool ; a thick layer of cotton 
batting is next applied over it, and it is then moulded to 
the part and held firmly in place by the turns of a roller 
bandage ; in a few hours it becomes dry and hard. 

This material, from its cheapness and the ease with which 
it is obtained, is frequently employed to mould splints for 
the treatment of fractures, especially in children, and for 
the fixation of joints in the treatment of acute and chronic 
joint affections. A moulded pasteboard splint is also often 
employed to fix the ends of the bones after the excision of 
a joint 

Porous Felt Splints. 

This material is also employed for the manufacture of 
splints, and is applied by dipping the material in hot water 
and then moulding it to the part ; as it dries it becomes 
hard. 

Hatter's Felt Splints. 

Hatter's felt is also frequently employed for the manu- 
facture of splints or dressings. It is softened by dipping it 
in boiling water or heating it in the flame of an alcohol 
lamp, and when soft and pliable it is moulded to the part, 
and as it cools it again becomes hard. 

These splints are employed for the same purposes as those 
made of plaster-of-Paris, leather, or pasteboard. 



PAET II. 

MINOR SURGERY. 



Theory of Asepsis and Antisepsis in WouDd 
Treatment. 

The term Asepsis, applied to wounds, implies that there 
is in the wound an absence of those vegetable parasites 
or microorganisms whose presence sets up fermentative 
changes, accompanied by suppuration and constitutional 
disturbance. 

Antisepsis, on the other hand, has reference to the means 
employed to bring about the destruction of microorganisms 
which may be present in the wound or upon the instru- 
ments, dressings, or hands of the surgeon, and which, if 
not destroyed or rendered inert, will set up fermentative 
changes in the wound. 

It has long been a well-recognized fact that albuminoid 
substances, such as dead animal tissue, blood, or blood- 
serum, will, when exposed to moisture, warmth, and the 
presence of certain living organisms or fungi, bacteria and 
micrococci, develop putrefactive changes ; and if these 
changes take place in the living body there result certain 
constitutional disturbances known as symptomatic, inflam- 
matory, or septic fever. 

It was also recognized that these putrefactive changes in 
albuminoid substances could be avoided by their exposure 
to heat, cold, or by drying — any of these conditions being 
sufficient to destroy or arrest the development of the micro- 
cocci. The microorganisms which set up fermentative and 
putrefactive changes in animal tissues exist in great variety. 



100 MINOR SURGERY. 

but those which are of most interest to the surgeon belong 
to the cocci and bacilli. 

Rosenbach's investigations have shown that the most 
common cause of suppuration in living human tissue is a 
minute globular micrococcus, to which the name staphylo- 
coccus pyogenes aureus has been given. This coccus is 
found in almost all varieties of acute suppuration. 

Another form of coccus which may exist alone or in con- 
nection with the previously mentioned fungus is the staphylo- 
coccus pyogenes albus. Both of these varieties of cocci, 
from the agminated arrangement of the single coccus, are 
known as grape cocci, and have the peculiarity of causing 
well-localized foci of inflammation. 

The streptococcus pyogenes, a pus-generating chain coccus, 
which extends rapidly along the lymph spaces and lym- 
phatics, and by rapid infiltration of the tissues causes 
spreading gangrene, is also of especial interest to the 
surgeon. 

Decomposition in tissues, accompanied by the presence of 
foul odors, is said always to be due to the action of rod-like 
bodies called bacilli or bacteria, such as the bacillus pyogenes 
foetidus and bacillus pyocyaneus. 

In wounds the result of accident or made by the surgeon, 
we have present conditions most favorable for the entrance 
and development of these organisms, such as the serum and 
blood, and the dead or partially devitalized cells of the vari- 
ous tissues which are exposed. We have present also warmth 
and moisture, and in the air coming in contact with the 
wound we have vast quantities of dust laden with spores, 
which under these favoring conditions develop into the or- 
ganisms before mentioned, which rapidly set up fermentative 
processes known as decomposition. 

The products of this decomposition, carried into the cir- 
culation by the lymphatics and veins, set up local changes 
in the shape of inflammation and at the same time give rise 
to systemic disturbances which we recognize as septic fever. 

Modern wound treatment aims at the prevention of de- 
composition and suppuration, and accomplishes this purpose 
by having the wound kept aseptic, by perfect cleanliness of 



DRYING AND CHEMICAL STERILIZATION. 101 

the region of the wound, the hands and instruments of the 
surgeon, and by not exposing the wound to an atmosphere 
which contains dust ; as the latter condition is difficult to 
obtain we secure the destruction of the microorganisms 
which may be present by heat, as seen in the use of the 
actual cautery, and by chemical sterilization, which is ac- 
complished by the use of germicides. 



Methods and Dressings Employed in Wounds to 
Secure Asepsis. 

To prevent infection of wounds the various chemical 
sterilizers and dressings are employed in different ways, and 
the principal types of dressings are as follows : 

Method by Simple Drying. 

This method is employed in small and not very deep 
wounds. The edges having been brought together by sutures 
the surface of the wound is dusted with powdered iodoform, 
the serum and blood forming with this, as it dries, a scab, 
which protects the wound from infection from without, and 
repair takes place promptly under this scab. Iodoform 
collodion may be employed instead of powdered iodoform in 
this method of dressing. 

Method by Drying and Chemical Sterilization. 

The object of this method of dressing is to provide a 
means of sterilizing the blood or serum which escapes from 
the wound, and at the same time to insure the sterilization 
of the air coming in contact with the discharges or the 
wound. 

It is employed in large or deep wounds, where there is 
always more or less escape of blood or serum, and is accom 
plished by applying a number of layers of sublimate or 
iodoform gauze and sublimated cotton over the wound. 
Evaporation not being interfered with, the whole dressing 
becomes hardened, and the wound is surrounded by a large 



102 MINOR SURGERY. 

antiseptic crust made up of the dressing and serum or 
blood. 

This method of dressing is the one most generally em- 
ployed at the present time. 

Moist Dressings. 

In this method of dressing, the wound is covered by moist 
gauze dressings and these are kept moist and evaporation 
is prevented by applying over them some impervious mate- 
rial such as mackintosh or rubber tissue. 

Modified Moist Dressing. 

In this method of dressing, the wound itself is covered by 
a piece of protective or rubber tissue ; over this is placed the 
sublimated or iodoform gauze dressing and some layers of 
bichloride cotton. By this method of dressing, the wound 
itself is kept in a moist condition favoring particularly the 
organization of blood clots ; the external dressings become 
dry as the discharges which have escaped into them evaporate, 
forming an antiseptic crust or covering over the wound. 

Surgical Cleanliness. 

In the practice of aseptic surgery it is a matter of the 
first importance that anything coming in contact with a 
wound should be absolutely clean, such as the hands of the 
operator, instruments, sponges, towels, ligatures, sutures and 
dressings. 

Antiseptic Substances Employed. 

A great variety of substances possessing more or less 
germicidal properties have been at different times employed 
in the practice of aseptic or antiseptic surgery ; those most 
employed at the present time are bichloride of mercury, 
carbolic acid, iodoform, beta-naphthol, chloride of zinc, per- 
oxide of hydrogen, creolin, permanganate of potassium, 
pyoktanin and boric acid, the double cyanide of mercury 
and zinc, and aristol. 



BICHLORIDE OF MERCURY. 103 



Bichloride of Mercury. 

This is employed as an antiseptic in watery solution, vary- 
ing in strength from 1 : 500 to 1 : 5000. 

The solution 1 : 500 to 1 : 1000 is used only for the irriga- 
tion and disinfection of the hands and skin ; for the irriga- 
tion of wounds, a solution of 1 : 2000 is generally employed. 
In using the bichloride solution in operations upon children, 
I am in the habit of using a solution of 1 in 4000, and I 
find that it produces less irritation of the skin and is equally 
efficient as a germicide. Where continuous irrigation is kept 
up or where it is employed in large cavities, a still weaker 
solution, 1 : 5000 to 1 : 10,000, should be employed. 

In using these solutions the surgeon should watch the 
patient carefully for symptoms of poisoning due to the 
absorption of the bichloride of mercury; the symptoms 
denoting this are vomiting, fetid breath, salivation, inflam- 
mation of the gums, diarrhoea, blood-stained stools, and 
bleeding from the mouth and nose. 

In preparing the solutions of bichloride of mercury for 
use, it will be found convenient to have a concentrated solu- 
tion of the salt in alcohol, one part of the bichloride of 
mercury to ten parts of alcohol ; this can be kept in a well- 
stoppered bottle, and to this should be added one teaspoon- 
ful of common salt, which prevents the disintegration of the 
mercuric compound. One teaspoonful of this solution added 
to one quart of water makes a 1:1500 solution. 

A 10 per cent, bichloride- solution may be made as follows : 

Bichloride of mercury 2 parts. 

Sodium chloride 1 part. 

Dilute acetic acid 1 " 

Water 16 parts. 

By adding water in an appropriate quantity, 1 : 1000 or 1 : 2000 solution 
can be made. 

Or the solution may be prepared with tartaric acid in the 
proportion of five parts of the acid to one part of the 
bichloride of mercury, the following formula being em- 



ployed : 



104 MINOR SURGERY. 

Hydrarg. chlor. corrosiv grs. xv. 

Ac. tartaric. grs. lxxv. 

Aquae dest Oij. 

Pellets containing a definite amount of bichloride of 
mercury compounded with a few grains of common salt or 
muriate of ammonia, which, when dissolved in a definite 
quantity of water, make a solution of 1 : 1000 or 1 : 2000, 
will also be found very convenient for the preparation of 
solutions. 

These bichloride or sublimate solutions are also employed 
to sterilize the gauze and cotton which are largely employed 
in antiseptic dressings. 



Carbolic Acid. 

This drug is employed in solutions of 1 : 20 or 1 : 40. The 
stronger solution, 1 ; 20, is usually employed to sterilize the 
instruments, the latter being allowed to remain in this solu- 
tion for thirty minutes before being used. As a carbolic 
solution of this strength benumbs and cracks the hands of 
the operator, it should be diluted just before the instruments 
are required, by adding an equal quantity of water, making 
it a 1:40 solution. 

The 1 : 40 solution is used for the irrigation of wounds 
and the washing of sponges. Carbolic acid is also employed 
in the preparation of gauze. A ready method of making a 
5 per cent, carbolic solution is to add one tablespoonful of 
carbolic acid to one quart of water. 

In using carbolic acid solutions the surgeon should be on 
the watch for the symptoms of poisoning, which will show 
itself by dark-colored urine, headache, dizziness, vomiting, 
and in severe cases bloody diarrhoea, hemoglobinuria, and 
death from collapse. Carbolic acid solutions should be used 
with great caution in young children, as they seem to be 
more susceptible than adults to the constitutional effects of 
this drug. I have seen the use of quite dilute solutions 
produce the characteristic symptoms of poisoning in such 
patients. 



BETA-NAPHTHOL 



Iodoform, 



Iodoform has been shown by experimental research to 
possess little germicidal action, but in spite of this fact clini- 
cal experience has proved that it possesses powerful anti- 
septic properties, due not to the destruction of germs, but to 
its undergoing a decomposition in their presence, and thus 
rendering the ptomaines which have resulted from the germ- 
growth inert. Iodoform may be rendered absolutely sterile 
by washing it in a 1 : 1000 bichloride solution, which de- 
stroys all microorganisms ; it should then be dried, and kept 
for use in closely stoppered bottles. 

Iodoform is very extensively employed as an application 
to wounds ; it is especially useful as a dressing to infected 
wounds, and to tubercular or syphilitic ulcers. It is also 
employed in the preparation of iodoform gauze, and may be 
combined with collodion to form iodoform collodion, which 
is a useful dressing in superficial wounds : 

Iodoform grs. xlviij. 

Collodion . . . . . ' %}• 

An ethereal solution of iodoform (iodoform grs. xv, ether 
Sj) is also used as an application to chronic ulcers. 

An emuhion of iodoform in glycerin (iodoform 5j, glycerin 
5x) is much employed at the present time as an injection in 
the treatment of chronic or tubercular abscesses. 

Elderly persons are more prone to the toxic action of 
iodoform than young persons. These symptoms are mani- 
fested by sleeplessness, debility, headache, delirium, and 
death may result from meningitis or cardiac depression. 



Beta-naphthol. 

Beta-naphthol, in a 1 : 2500 solution, is employed for 
much the same purposes as the bichloride of mercury solu- 
tion ; it is not, however, so powerful a germicide. It is 
employed in irrigating large cavities because it is not a 
poisonous agent, but is especially useful as a bath for instru- 



106 MINOR SURGERY. 

ments, as it does not corrode them, as does the sublimate 
solution. It also possesses the advantage over a carbolic 
acid solution of not irritating the skin of the surgeon's hands. 

Chloride of Zinc. 

Chloride of zinc, in a solution of 30 to 40 grains to 
water fgj, is a very powerful antiseptic. When employed 
upon raw surfaces it produces marked blanching of the 
tissues ; it is especially useful in wounds which are infected 
or which have been exposed to infection. I have found it 
by all means the best application to the poisoned wounds 
which are received in dissecting dead bodies and in oper- 
ating. In such cases the whole cavity or surface of the 
wound should be washed with a 30-grain solution of the 
chloride of zinc, and then the wound should be dressed with 
a bichloride dressing. 

SULPHO-CARBOLATE OF ZlNC. 

This drug has been found to possess more decided anti- 
septic properties than the chloride of zinc, and is much less 
irritating. It may be used in the same strength and for the 
same purposes as the former drug. 

Peroxide of Hydrogen. 

This drug is employed in what is known as a 15-volume 
solution, which may be diluted from 10 per cent, upward or 
used in full strength. It is employed in the sterilization of 
sinuses or suppurating cavities,. such, for instance, as often 
result from diseases of or operations upon bone. It seems 
to have a direct action upon pus generation by destroying 
the microorganisms of pus. It is injected into sinuses and 
cavities by means of a syringe, or may be applied to open 
wounds in the form of a spray ; its action is shown by the 
escape of bubbles of air, and it should be used as long as 
these continue to escape. 



BORO-SALICYLIC LOTION. 107 

Kreolin or Creolin. 

This substance is obtained from English coal by dry distil- 
lation, and has been found to possess powerful germicidal 
properties ; it is non-irritating and practically non-toxic. It 
is insoluble in water, but forms an emulsion with it which 
possesses marked germicidal properties. It is employed for 
the same purposes as carbolic acid, and has the advantage 
over the latter drug that it is not irritating to the skin, and 
is almost devoid of toxic properties. 

It is used in an emulsion, in strength from two to five per 
cent., and is employed in the irrigation of large wounds or 
cavities of the body, and has been most favorably recom- 
mended in gynecological practice. As a bath for instru- 
ments to render them sterile during operations it is useful, 
but the opacity of the emulsion makes it difficult to find the 
instruments and interferes with its efficiency. 

Boric Acid. 

This drug has not very marked antiseptic qualities, but is 
unirritating even in saturated solutions. It is frequently 
employed in a 5 to 30 per cent, solution to cleanse and dis- 
infect mucous surfaces and large cavities. It is often em- 
ployed to wash out the bladder before the operation for the 
removal of calculi or growths from that organ. 

In the dressing of superficial wounds, or in wounds in 
which the bichloride or carbolic acid dressings produce irri- 
tation, an ointment of boric acid, made by taking boric 
acid 1 part, vaseline 5 parts, will be found very satisfactory. 

BORO-SALICYLIC LOTIOX. 

This lotion is prepared by adding 2 parts of salicylic acid 
and 12 parts of boric acid to 1000 parts of hot water. 
This forms a very bland solution, which can be used where 
there is danger in using bichloride or carbolic solutions — as, 
for instance, in the bladder or peritoneal cavity. 



108 MINOR SURGERY. 



Permanganate of Potassium. 

This drug, owing to its rapid absorption of oxygen, acts 
as an antiseptic, and is often employed for the disinfection 
of foul wounds and ulcers. It is also employed in solution 
for washing the operator's hands, and for the washing of 
sponges. It is pratically non-irritating, and may be used in 
quite concentrated solutions, but is usually employed in the 
following solution : Permanganate of potash 5j, water f §j. 
One fluid drachm of this solution to a pint of water makes 
a 1 : 1000 solution. 

Pyoktanin. 

Methyl-violet, known in commerce under the name of 
pyoktanin, has been recommended as a drug possessing 
marked antiseptic powers. It is said to prevent suppuration 
by destroying the organisms which are active in its produc- 
tion, which are said to have an affinity for and are killed by 
aniline colors. It has been claimed that it sterilizes the pus 
of suppurating wounds and ulcers, and it is recommended as 
an injection in the treatment of large suppurating cavities 
for this purpose, as it is practically non-poisonous. 

It is employed in a solution of a strength of 1 : 1000 or 
1 : 2000, and for the sterilization of surgical instruments a 
1 : 10,000 solution may be employed. When employed as 
a means of irrigating wounds, it should be used until the 
tissues are of a deep-blue color. Recent investigations have 
shown that it is, as a germicide, much less reliable than 
bichloride of mercury. 

Aristol. 

Aristol, which is a compound of iodine and thymol, pos- 
sesses germicidal properties and has been introduced as a 
substitute for iodoform. It has the advantage over iodoform 
of not being poisonous and is also without disagreeable odor. 
It may be employed for the same purposes as iodoform and 



SPONGES. 109 

it seems to be particularly useful as a dressing to chronic and 
specific ulcers. 

Double Cyanide of Mercury and Zinc. 

Cyanide of potassium, cyanide of mercury, and sulphate 
of zinc are mixed together in solution, in quantities propor- 
tioned to the atomic weights of 2KCy, HgCy 2 and ZnS0 4 
-f 7H 2 ; the cyanide of potassium and cyanide of mercury 
being dissolved together in one and a half ounces of water 
for every 100 grains of potassium cyanide, are added to the 
sulphate of zinc dissolved in three times that amount of 
water. The precipitate is collected and washed in two suc- 
cessive portions of water equal in quantity to that used for 
the solutions, that is six ounces of water for every 100 
grains of the potassium cyanide, to free the precipitate from 
the irritating salts associated with it in its formation. The 
precipitate being well washed, is next mixed with distilled 
water containing one part of hematoxylin for every 100 
parts of the cyanide salt ; this, when it precipitates the cyanide 
salt, changes its color to a pale bluish tint. 

Ammonia is next added in such a proportion to the mix- 
ture that one fluidrachm of the ammoniacal liquid shall 
correspond with one grain of hsematoxylin, and the ammoni- 
acal mixture is allowed to stand for three or four hours, 
when it is filtered and the dyed salt is drained and dried at 
a moderate heat, is next levigated and may then be kept for 
any length of time for use. When employed for charging 
gauze it is mixed with a 1 : 4000 bichloride solution in the 
proportion of four pints of the solution to 100 grains of the 
salt. 

Preparation of Materials Used in Aseptic Surgery 
and Dressings. 

Sponges. 

Sponges, while dry, should be beaten to free them from 
calcareous matter, then placed in a 15 per cent, solution of 
hydrochloric acid for thirty minutes to dissolve any lime 

6 



110 MINOR SURGERY. 

which may remain in them ; they should then be removed 
from this solution and washed, and should next be well 
washed with green or castile soap and warm water for a few 
minutes and then thoroughly rinsed and placed in a 1 : 1000 
bichloride solution or in a 5 per cent, carbolic solution in 
closely covered jars until required for use. 

Or, after beating the sponges to remove any sandy matter, 
they may be placed for twenty-four hours in a solution of 
hydrochloric acid — hydrochloric acid §iv, water four pints — 
then removed and washed until free from acid, then steeped 
for half an hour in a solution of permanganate of potassium, 
180 grains to six pints of water. Next wash them and 
place them in the following solution : hyposulphite of sodium, 
§x ; hydrochloric acid, f §v; water, f glxviij ; and allow them 
to remain in this solution for four hours ; remove them from 
this and place them in running water for six hours ; they 
should then be placed in jars and covered either by a 5 per 
cent, carbolic acid solution or a 1 : 1000 bichloride solution. 
The carbolic acid solution is better for keeping the sponges 
than the sublimate solution, as it does not decompose. 

They may be prepared also by beating and washing 
them, and then soaking them for twelve hours in a solution 
of chlorinated soda — chlorinated soda 1 part, water 5 
parts. They are then removed and well' rinsed and placed 
in a 5 per cent, carbolic solution, or they may be placed in a 
moderately warm oven until thoroughly dry, and then placed 
in air-tight jars, if it is desired to keep them dry. 

It is better to use a cheaper grade of sponges, and to use 
them only once, but if the same sponges are to be used 
again, they should be well washed in a solution of carbonate 
of soda, 1 ounce to the quart, and then placedin a 1 : 1000 
bichloride solution. 

Silk. 

Silk for sutures or ligatures should be sterilized by boiling 
for thirty minutes in a 5 per cent, solution of carbolic acid 
or water, then placed in stoppered bottles and covered with a 
5 per cent, solution of carbolic acid or with absolute alcohol. 



catgut ligatures or sutures. ill 

Silkworm-gut. 

Silkworm-gut is an excellent material for sutures, and is 
much easier to thread than the silk or catgut. It may be 
kept dry in glass jars, or preserved in alcohol, and should be 
placed in a 5 per cent, carbolic solution for a few minutes 
before being used, as this renders it more supple. 

Catgut Ligatures or Sutures. 
Juniper Catgut. 

Catgut, varying in size from No. 0, which is very fine, to 
No. 4, which is quite thick, is placed in oil of juniper ber- 
ries for one week, and is then transferred to absolute alco- 
hol, in which it should be kept until required for use. 

No. 1 catgut is the size usually employed for ligatures 
and sutures. 

Alcohol is the best material in which to preserve the cat- 
gut, as it keeps it firm, and does not interfere with its flexi- 
bility, while both carbolic acid and bichloride solutions render 
it brittle and weak. 

Chromic Acid Catgut. 

The catgut is first washed in alcohol and placed in 1 
quart of a 5 per cent, solution of carbolic acid, containing 
30 grains of bichromate of potassium, and is allowed to 
remain for forty-eight hours. This immersion should be 
longer when large-sized varieties of catgut are used; but 
for the sizes of catgut which are ordinarily used, this time 
of immersion will prepare the gut to resist the action of the 
living tissues for a week or more. Catgut thus prepared 
may be dried and placed in closely stoppered jars, or may be 
kept in alcohol. 

Catgut may also be prepared by soaking it in alcohol for 
a short time, and then placing it in the following solution 
for forty-eight hours : Chromic acid, 1 grain ; carbolic acid, 



112 



MINOR SURGERY 



IS 



200 grains ; alcohol, 2 drachms ; water, 2J ounces. It 
then removed and placed in glass jars for use. 

Before being used it should be soaked for thirty minutes 
in a 5 per cent, carbolic acid solution, or in a 1 : 1000 bichlo- 
ride solution. 

The chromic acid catgut is by far the best variety of gut 
to use for sutures and for the ligation of the larger vessels 
in their continuity. 



Drainage-tubes. 

The drainage-tubes usually employed are prepared from 
rubber tubing of different sizes perforated at short intervals ; 

Fig. 82. 




Rubber drainage-tube. 



the black rubber tubes are softer and more pliable than the 
red or white rubber tubes, and should be preferred. (Fig. 
82.) Drainage-tubes are also made of glass (Fig. 83), which 



PROTECTIVE. 113 

are almost exclusively used in abdominal surgery, and also 
of decalcified bone. Drainage-tubes should be kept in a 6 
per cent, solution of carbolic acid, or, if kept dry, they 

Fig. 83. ' 




G-lass drainage-tube. 

should be well washed and placed in a carbolic or bichlo- 
ride solution for thirty minutes before being used. 

Horse-hair and Catgut for Drainage. 

Catgut as ordinarily prepared for ligatures may be used 
to secure drainage in small and superficial wounds ; a num- 
ber of strands of catgut are placed in the bottom of the 
wound, and the end or ends are allowed to project from one 
or both extremities of the wound. 

Horsehair may be employed for the same purpose, a 
number of strands of the hair being placed in the wound in 
the same manner. Before being used it should be well 
washed with soap and water and then soaked in a 5 per 
cent, carbolic solution or 1 : 1000 bichloride solution for 
thirty minutes. 

Protective. 

Protective is employed to prevent the wound from being 
irritated by the antiseptic substances with which the gauze 
is impregnated or by its irregular surface. 

Various materials are employed as protectives, the principal 
requirement being that it is some tissue which can be readily 
rendered aseptic, and does not absorb any irritating materials 
from the dressings. 

The protective first employed by Mr. Lister, which is still 
generally employed, is prepared by coating oiled silk with 



114 MINOR SURGERY. 

copal varnish, and when this is dry a mixture of 1 part of 
dextrine, 2 parts of powdered starch, and 16 parts of a 
1 : 20 carbolic acid solution is brushed over its surface. 

Rubber tissue may be employed very satisfactorily as a 
substitute for this protective. 

Before applying the protective to the wound, it is dipped 
into a solution of bichloride of mercury or carbolic acid. 

Mackintosh. 

This consists of cotton cloth, with a thin layer of India- 
rubber spread on one side. It is employed in antiseptic 
dressings as a layer of dressing outside of the gauze, and 
should be applied with the rubber surface toward the wound, 
to prevent the discharge from the wound from soaking 
directly through the dressing. 

The mackintosh cloth is not at the present time as much 
employed as formerly, unless the moist method of dressing 
is adopted. 

Rubber Tissue. 

This consists of a very thin sheet of India-rubber with 
glazed surfaces, which can be obtained from the rubber 
manufacturers ; it is employed for the same purposes as 
the mackintosh, is much less expensive, and, as previously 
stated, may be used instead of protective for covering the 
wound. 

Parchment Paper. 

This consists of a very tough paper material which can be 
soaked in a watery solution of corrosive sublimate or carbolic 
acid without becoming so much softened as to tear upon 
handling. It is prepared by the manufacturers of surgical 
dressings, and is employed for the same purposes as mack- 
intosh. 



peep a ratio x of gauze dressing. 115 

Gauze Dressings. 

The most convenient and cheapest material for wound- 
dressing is a sheer material known in the trade as cheese or 
tobacco cloth. By reason of having a very open mesh it 
absorbs well either the materials with which it is prepared 
or the discharges from the wound when applied as a dress- 
ing. It can be readily obtained anywhere, is inexpensive, 
and is soft and pliable, so that it is a comfortable form of 
dressing to the patient. The gauze is impregnated with 
different materials to render it antiseptic, and its preparation 
is a matter of little difficulty. 



Preparation of Gauze Dressing. 

Bichloride of Mercury or Corrosive Sublimate 
Gauze. 

In preparing bichloride or corrosive sublimate gauze, 
thirty yards of cheese-cloth are placed in a wash-kettle and 
covered with water, to which is added two pounds of wash- 
ing soda or a pint of lye, and boiled for an hour ; the soda 
or lye is added to remove any oily matters which the cheese- 
cloth contains, and thus make it more absorbent. The 
gauze is next removed from the water and washed in clear 
water, and passed through a clothes-wringer, and then im- 
mersed in a 1 : 1000 bichloride of mercury solution for 
twenty-four hours. It is then dried and cut into pieces 
several yards in length, and packed in closely covered glass 
jars or tin boxes and put away for use. Or it may be pre- 
served as moist gauze by packing it in air-tight jars. If 
gauze has been prepared for some time, it is well to soak it 
for a short time in a 1 : 1000 bichloride of mercury solution 
before using it. 

In using the sublimate gauze on delicate skins there will 
sometimes result a dermatitis which is known as mercurial 
eczema ; this is particularly apt to occur if the gauze is 



116 MINOR SURGERY. 

moistened or covered with rubber tissue or mackintosh. If 
this condition develops, the parts covered by the gauze 
should be rubbed over with boric acid ointment or vaseline 
before it is reapplied, or another variety of dressing may have 
to be substituted, such as the iodoform or carbolized gauze. 

Iodoform Gauze. 

Iodoform gauze may be prepared by sprinkling cheese- 
cloth, which has been boiled in soda solution, with powdered 
iodoform and rubbing it well into its meshes; it should then 
be dried and packed in glass jars for use. 

It may also be prepared by rubbing an emulsion of iodo- 
form, made by adding 3 drachms of iodoform to 6 ounces of 
Castile soap-suds, into 18 ounces of moist gauze; this should 
be dried and packed in glass jars for use. 

Double Cyanide oe Mercury and Zinc Gauze. 

The preparation of this gauze is much more difficult than 
that of the other varieties of gauze, requiring the following : 

Potass, cyanide 130 grains. 

Mercuric cyanide 251.7 " 

Zinc sulphate 268 9 " 

Hematoxylin 1.3 " 

Sal ammonia (gas NH 3 1 per cent.) ... 6 minims. 
Gauze (previously boiled and dried) . . 10 ounces. 

Bichloride of mercury solution ... 7.6 pints. 

Distilled water q. s. 

In charging gauze with this substance, 100 grains of the 
salt are dissolved in 4 pints of a 1 : 4000 bichloride solu- 
tion, which will give from 2 to 3 per cent, of the cyanide 
to the dry gauze. The gauze should be freshly prepared 
and used moist, or if allowed to become dry it should be 
moistened again with a w r eak bichloride solution before being 
used. The advantages claimed for this gauze are that it is 
not irritating to the skin, and as the antiseptic is not soluble 
it is not washed out by the discharges from the wound. 



MOSS DRESSING. 117 

Prof. J. William White, who has used it extensively in his 
practice, considers that it possesses decided advantages over 
the bichloride gauze.- 

Carbolized Gauze. 

The carbolized gauze which is used in the University 
Hospital is prepared in the following manner : Cheese- 
cloth, which has been previously boiled and dried, is soaked 
for a few hours in the following solution: 

Resin 1 pound. 

Alcohol 5 pints. 

Castor oil 24 ounces. 

Carbolic acid 12 " 

The gauze is next removed from this solution and passed 
through a clothes-wringer, and is then cut in pieces four to 
six yards in length, which are folded and packed in air-tight 
tin boxes for use. 



Sawdust Dressing. 

Sawdust is impregnated with a 1 : 1000 bichloride of 
mercury solution for twenty-four hours, and then spread out 
to dry ; after it has become sufficiently dry it is enclosed in 
bags made of cheese-cloth of various sizes. This will be 
found to be a satisfactory substitute for the ordinary gauze. 
In using this dressing the w r ound should be covered with a 
piece of protective or a few layers of gauze, and the bags 
are then packed over this and held in place by a bandage. 

Moss Dressing. 

Different species of sphagnum or moss, on account of their 
cheapness, elasticity, and great absorbing power, have been 
found a very satisfactory material with which to make dress- 
ing bags. 

Clean moss is soaked for twenty-four hours in a 1 : 1000 
bichloride of mercury solution and then dried ; cheese-cloth 

6* 



118 MINOR SURG-ERY. 

bags are filled with this material and may be used dry or 
may be moistened with 1 : 3000 bichloride solution before 
being applied in the dressing of wounds. They are much 
employed in the hospitals of Germany, and have largely 
superseded the gauze dressings. 

Improvised Antiseptic Dressings. 

In cases of emergency, when the ordinary gauze dress- 
ings cannot be obtained, it is well to remember that old 
muslin or linen, which can usually be obtained, will serve 
for a temporary dressing if properly sterilized, until a more 
elaborate dressing can be applied. Old sheets either of 
muslin or linen should be torn into pieces half a yard 
square and thrown into boiling water ; after remaining for a 
few minutes in this they should be removed and soaked for 
a few minutes in a 1 : 1000 or 1 : 2000 bichloride solution, 
or a 5 per cent, carbolic solution, and applied to the wound, 
a number of layers of this material being applied and held 
in position by a bandage. This dressing will keep the 
wound aseptic until a more elaborate dressing is obtained. 

Antiseptic Bandages. 

These bandages are prepared by tearing or cutting bichlo- 
ride or carbolized gauze into strips two to three inches in 
width and five yards in length, and forming the strips into 
rollers and packing them in air-tight vessels. 

The bandages may also be prepared from boiled dry gauze 
in the same manner, and are kept in air-tight boxes or jars 
until required for use, when they are soaked for a few min- 
utes in a 1 : 1000 bichloride or 5 per cent, carbolic solution. 

They may also be. prepared from crinoline, the same 
material which is used for the plaster-of- Paris bandage ; as 
this material is quite stiff, the bandage should be soaked in 
a bichloride or carbolic solution before being applied, and as 
the material contains a certain amount of starchy matter, it 
becomes firm as it dries and makes a very secure dressing. 



BICHLORIDE COTTOX 



119 



For this reason it is often applied over the ordinary anti- 
septic bandage. 

Bichloride Cotton. 

This material, which is an important part of most anti- 
septic dressings, is prepared by soaking absorbent cotton in 
a 1 : 1000 bichloride of mercury solution for twenty-four 
hours, and then allowing it to dry. When dry, it is packed 
in jars or air-tight boxes. Its great absorbing power and 

Fig. 84. 




Sterilizing: oven. 



its elasticity make it, when properly prepared, a most valu- 
able dressing ; it is generally employed to cover the gauze 
dressing, a number of layers being applied. 



120 MINOR SURGERY. 

Borated, carbolized, and salicylated cotton, prepared in 
the same manner, are also frequently employed for a similar 
purpose. 

Dry Sterilized Dressings. 

These dressings are prepared by sterilizing ordinary gauze 
with steam. Gauze cut into proper lengths is placed in wire 
cases and exposed to super-heated steam in an oven for a 
few hours, and is then dried in another oven, removed, and 
placed in air-tight jars or boxes The apparatus required 
for perfect sterilization of dressings is expensive, and is not 
likely to be employed by practitioners, but is used in hos- 
pitals where a large number of dressings are constantly 
required. A convenient form of sterilizing oven is shown 
in Fig. 84. Unless the sterilization is perfect, these dressings 
should not be employed ; the same method is employed in 
the sterilization of instruments. 



Preparation for Aseptic Operation. 

Surgical Cleanliness. 

TJie Rands. 

The hands and forearms of the surgeon and of his assist- 
ants should be well washed in hot water with soap for a few 
minutes, and a nail-brush should be used to cleanse the 
region of the finger-nails ; rings with irregular surfaces 
which might retain filth should be removed. After the 
hands and forearms have been thoroughly cleansed, they 
should be immersed in 1 : 1000 bichloride solution for a 
short time. 

The same precautions should be taken with the hands 
and forearms of nurses who handle the instruments and 
dressings. If in any manner the hands of the surgeon or of 
his assistants come in contact, during the operation, with any 
objects which have not been disinfected, such as the clothing 



PREPARATION FOR OPERATION. 121 

of the patient, the operating-table, etc., it is a matter of the 
first importance that they should be thoroughly washed and 
disinfected before again being brought in contact with the 
wound. 

Sterilizing of Instruments. 

The instruments should be carefully scrubbed with warm 
water and soap, care being taken to see that all joints and 
roughened surfaces are freed from any dry matter which 
may adhere to them ; after being thoroughly cleansed in 
this manner, they should be placed in a metal or porcelain 
tray and covered by a 5 per cent, carbolic solution for fifteen 
minutes before being used. 

The instruments which are now constructed with metal 
handles may be sterilized by placing them in boiling water, 
or by boiling them ; where instruments are employed which 
have wooden handles this method of sterilization cannot be 
employed, and here it will be found necessary to resort to 
the first method of sterilization. 

Instruments which fall upon the floor or come in contact 
with the clothing of the surgeon or the patient during the 
operation, should be washed and placed in the carbolic solu- 
tion before again being brought in contact with the wound. 

Preparation of the Patient for Operation. 

The patient having been prepared for the operation by 
whatever constitutional treatment the surgeon considers 
necessary, the region of the proposed wound is first rubbed 
over with cotton saturated with spirits of turpentine, and 
next is thoroughly washed with soap and water ; if hairs are 
present in the region they should be shaved off; after a careful 
washing with soap and water, the skin is carefully washed 
with a 1 : 1000 bichloride or 5 per cent, carbolic solution, 
and is then covered with a towel wrung out in a 1 : 2000 
bichloride solution until the surgeon is ready to begin the 
operation. 

This cleansing of the region of the proposed wound in 



122 MINOR SURGERY. 

hospital practice is generally made a few hours before the 
operation, but in private practice it has to be done just before 
the operation is undertaken ; but if carefully done the results 
will be in no wise less satisfactory. In private practice the 
operation may have to be performed while the patient is in 
his bed, or, if an ordinary kitchen-table is at hand, it will be 
found more convenient to place him upon this ; this should 
be prepared by placing upon it a folded quilt or blanket, 
and over this a sheet of rubber cloth, and upon this is laid 
a clean, folded, linen or muslin sheet. The surgeon should 
carry with him a sheet of this rubber cloth, three by four 
feet, which he will find most useful in preparing the table 
for the operation, or in protecting the bed of the patient 
if he is not placed upon the table; a rubber cloth of this 
size takes up little space if carefully folded, and can be easily 
packed in the instrument-bag. 

Details of an Aseptic Operation. 

The patient being anaesthetized and placed upon the table, 
the clothing is so arranged as to expose freely the part to be 
operated upon ; the clothing or the skin surrounding this 
region is next covered with towels wet with a 1 : 1000 bichlo- 
ride solution. If any considerable surface of the patient's body 
is covered by these towels, to avoid chilling the surface and 
adding to the shock which naturally follows the operation, 
they should be wrung out in a hot bichloride or carbolic solu- 
tion, and should be replaced as they become cold by hot towels 
prepared in the same manner. The patient being ready for 
operation, the surgeon should assign the assistants and nurses 
their duties, and having again immersed their hands and fore- 
arms in the bichloride solution the operation is begun. 

During the operation the wound is irrigated frequently 
with a 1 : 2000 or 1 : 3000 bichloride solution, which may 
be allowed to run over the wound, or be applied by means 
of a syringe or irrigating apparatus (Fig. 85), and the hands 
of the surgeon and assistants should also be washed in this 
solution at not too long intervals. In prolonged operations, 



DETAILS OF AN ASEPTIC OPEKATION. 123 

or in those in which a large wound is made, I think it is 
especially important that the irrigating solutions should be 
used as warm as can be comfortably borne by the hands of 
the surgeon ; warm solutions, it has been shown by recent 

Fig. 85. 




Irrigating apparatus. (Esmarch.) 

investigations, possess a greater germicidal power than those 
of the same strength when used cold, and they also possess 
the advantage of preventing the chilling of the patient, and 
thus diminish the shock of the operation. 

Hemorrhage during the operation is controlled by the 
use of haemostatic forceps, which are applied to the bleeding 
vessels, or the vessels may be ligatured as they are divided. 
After the operation has been completed, and all hemorrhage 
has been controlled, the wound is thoroughly irrigated with 
a 1 : 2000 or 1 : 3000 bichloride solution. 

The next step is to provide for drainage ; this may be dis- 
regarded in small or superficial wounds, but in a wound of 
any considerable size or depth it is safer to provide free 
drainage. This is accomplished by the use of perforated 
rubber drainage-tubes, or a number of strands of catgut or 
horsehair, or by decalcified bone or glass drainage-tubes. 



124 MINOR SURGERY. 

The rubber tube in large wounds will be found most 
comfortable to the patient and satisfactory as regards drain- 
age ; it may be laid in the wound, the ends being allowed 
to extend from the extremities of the wound, or it may be 
so introduced that one end of the tube rests in the deepest 
part of the wound and the other extremity is brought out of 
the wound at its most dependent portion ; in large or irregu- 
larly shaped wounds a number of tubes may be required 
to secure free drainage. The ends of the drainage-tubes 
are transfixed with safety pins which have been sterilized and 
allowed to remain in a 5 per cent, carbolic solution until 
required, and the ends of the tube should next be cut off 
close to the pins so as to be as nearly as possible flush with 
the skin. 

The wound is next closed by the introduction of sutures, 
which may be of silkworm-gut, chromicized catgut, silk, or 
silver wire ; the needles and sutures should be soaked in a 5 
per cent, carbolic solution for thirty minutes before being 
used. The wound being closed, a final irrigation of its 
deepest parts should be made, by injecting a stream of bichlo- 
ride solution, 1 : 2000 or 1 : 3000, into the end of the drain- 
age-tube ; if through-and-through drainage has been em- 
ployed, one end of the tube should be closed and the solution 
should be injected into the wound through the other end of 
the tube by means of a syringe or irrigating-tube, until the 
wound is slightly distended with the solution, which allows the 
latter to find its way to all parts of the cavity of the wound. 
The external surface of the wound and the skin for some dis- 
tance surrounding it should next be washed with a 1 : 2000 
bichloride solution, and a piece of protective, a little longer 
and wider than the wound, is next dipped in a bichloride or 
carbolic solution and placed over it, and over this is laid the 
deep dressing, which consists of a pad of bichloride gauze from 
eight to sixteen layers in thickness and large enough to overlap 
the wound two or three inches in all directions. This should 
be dipped in a 1 : 2000 bichloride solution, and wrung out as 
dry as possible before being applied. The superficial gauze 
dressing is next applied, and consists of sixteen layers of 
gauze, which should be large enough to extend from three to 



REAPPLICATION OF PRESSINGS. 125 

six inches beyond the wound in all directions ; this gauze is 
applied dry. Over the superficial gauze dressing there is next 
applied a number of layers of bichloride cotton, so arranged 
as to extend a little beyond the margin of the superficial 
gauze dressing. These dressings are now secured in posi- 
tion by the application of a gauze bandage, which is pre- 
vented from slipping by the introduction of a few safety- 
pins. 

The dressing being completed, the patient is moved from 
the operating-table to his bed, and care should be exercised 
to see that the dressings do not become soiled if the patient 
vomits upon coming up from the anaesthetic. 

In this method of dressing no mackintosh or rubber tissue 
is employed, outside of the superficial gauze dressing ; the 
discharges from the wound are disseminated through the 
dressing and become dry by evaporation, and the dressing 
forms an antiseptic scab which covers and surrounds the 
wound. 

Moist Method of Dressing. 

If, for any reason, it is desired to adopt the moist method 
of dressing, a piece of mackintosh or rubber tissue larger than 
the superficial gauze dressing is placed over it, and over this 
is placed a few layers of bichloride cotton, care being taken 
to see that the layers of cotton overlap the mackintosh or 
rubber tissue by a few inches ; the application of an anti- 
septic gauze bandage then completes the dressing. On the 
removal of this dressing the gauze will be generally found 
to be soaked with the discharges from the wound, and in a 
moist condition. The disadvantage of this variety of dress- 
ing is that there is apt to be more irritation of the skin set 
up by the bichloride gauze when kept moist than when ap- 
plied in the manner of a dry dressing. 

Reapplication of Dressings. 

The re-dressing of a wound which remains aseptic need 
not be made for some days ; if the temperature remains 



' 126 MINOR SURGERY. 

normal or a little above this point, and the patient exhibits 
no unfavorable constitutional symptoms, and the dressing is 
comfortable to the patient, it need not be disturbed for a 
week or ten days ; at the expiration of this time it is well 
to examine the wound and to remove the drainage-tube if a 
drainage-tube has been used, and to remove a portion or all, 
of the sutures if the superficial parts of the wound are 
firmly healed. 

In re-dressing an aseptic wound at the end of a week or 
ten days, to prevent any possible infection, as much care 
should be exercised as in the original dressing of the wound. 
The patient's clothes should be removed so as to freely 
expose the dressing, and a rubber cloth should be placed 
under the patient so as to protect the bed, and the clothing 
and skin in the region of the wound should be protected by 
towels wrung out in a 1 : 1000 bichloride solution. The 
surgeon should wash his hands and immerse them in a 1 : 1000 
bichloride solution before removing the dressings. The 
bandage retaining the dressing should be divided with ban- 
dage scissors and the dressings should be removed layer by 
layer, and when the deep dressing is removed care should 
be taken to see that the drainage-tubes are not pulled upon 
if they are adherent to the dressing ; the protective should 
next be removed, and the surface of the wound should be 
irrigated with a 1 : 2000 bichloride solution ; the drainage- 
tubes should next be inspected to see that they are free, 
and a stream of bichloride solution may be passed through 
them by means of a syringe. If the wound is found aseptic 
the drainage-tube may be removed, and the wound should 
next be irrigated through its track by a stream of bichloride 
solution. If the wound is healed the sutures may be re- 
moved at this dressing; but if the wound has been an 
extensive or deep one it may be well to remove only a por- 
tion of the sutures ; if animal sutures have been employed, 
they need not be removed. The surface of the wound is 
next washed with a 1 : 2000 bichloride solution and a piece 
of protective is placed over the line of incision, and the 
deep and superficial dressings are applied as previously de- 
scribed and covered with layers of bichloride cotton, and 



REAPPLICATION OF DRESSINGS. 127 

the whole dressing is secured by the application of an anti- 
septic bandage. If the wound remains aseptic after this 
dressing, the dressings need not be changed for a week or 
ten days, and at this time the wound will usually be found 
healed, so that further dressings are not required. 

If, however, the wound is not running the typical course 
of an aseptic wound, constitutional symptoms will be devel- 
oped, as evidenced by a rise in the temperature and pulse- 
rate and other constitutional disturbances. In this event 
the wound should be re- dressed as soon as possible, and if 
the cause of the disturbance can be found it should be re- 
moved; for instance, hemorrhage may have taken place into 
the wound, and the blood not being able to escape through 
the drainage-tubes may have caused so much distention of 
the wound that the vitality of the skin covering the wound 
is threatened, or the sutures may be found to be causing 
irritation, or suppuration may be found to be present. 

If, on exposure of the wound, it is found that it is dis- 
tended with blood-clots, and blood is escaping from the 
wound, the sutures should be removed, the clots should be 
turned out, and the bleeding vessel or vessels should be 
sought for and ligatured, and the wound, after a thorough 
irrigation with 1 : 2000 bichloride solution, should be drained 
and closed with sutures, and dressed as previously described. 

If, however, on exposure of the wound, and upon the 
removal of a portion or all of the sutures, the wound is 
found distended with a blood-clot, and no evidence of hem- 
orrhage at the time exists, or of suppuration in the wound, 
the clot may be allowed to remain in place, and the wound 
should be re-dressed as in the original dressing, trusting to 
the organization of the blood-clot if it has remained aseptic. 
If the patient's condition improves after the dressing, and 
the temperature and pulse-rate become normal, it is an 
indication that the wound is still aseptic, and it need not 
be re-dressed for some days. 

If, on the other hand, examination of the wound shows 
that the drainage is insufficient, or that the drainage-tubes 
are occluded by blood-clots, these should be removed by 
washing out the tubes with a 1 : 2000 bichloride solution by 



128 MINOR SURGERY. 

means of a syringe, and introducing additional drainage- 
tubes, if it is deemed necessary ; the wound should then be 
re-dressed. 

When it is found on examination of the wound that sup- 
puration is present, the surgeon may adopt one of two 
methods of treatment : he may thoroughly wash out the wound 
through the drainage-tubes with a 1 : 2000 bichloride solu- 
tion, and after thorough irrigation of the wound re-dress 
it, and, if the patient's constitutional symptoms improve, he 
may be assured that the wound has been rendered aseptic, 
and is running an aseptic course. 

If he does not feel that this method of treatment is sufficient, 
he may open the wound and wash it thoroughly with a 
1 : 2000 bichloride solution, and next apply to its surface a 
15-volume solution of the peroxide of hydrogen, which may 
be diluted with water one-third or one-half, or a 30-grain 
solution of chloride of zinc may be used; and after this 
application a final irrigation with the 1 : 2000 bichloride 
solution shall be made, and it should then be drained, closed, 
and dressed, as previously described. 

If the treatment instituted to render the wound aseptic 
has been successful, the patient's constitutional condition 
will improve, and it will heal as an aseptic wound. 

Dressing of Septic Wounds. 

It often happens that patients suffering from wounds which 
have been improperly treated, or have had no treatment, 
come under the care of the surgeon ; such wounds are 
already infected, and to render them aseptic, if possible, the 
following treatment should be adopted : The skin surround- 
ing the wound should be carefully washed with spirits of 
turpentine, and then with soap and water, and finally with 
a 1 : 2000 bichloride solution. The wound itself should 
be next exposed as fully as possible, and any foreign bodies 
which are found in it, or dirt, should be removed with for- 
ceps and a stream of water ; it should next be thoroughly 
irrigated with a 1 : 2000 bichloride solution, and then should 
be drained, closed, and dressed as an operation wound. 



MATERIALS USED IX SURGICAL DRESSINGS. 129 

If suppuration is already present, after cleansing the 
region of the wound it should be irrigated with a 1 : 2000 
bichloride solution, and should next be washed with a 30- 
grain solution of chloride of zinc, or a 15-volnme solution of 
the peroxide of hydrogen diluted with water one-half, one- 
third, or used in its full strength : and finally thoroughly 
irrigated with a 1 : 2000 bichloride solution. 

The introduction of drainage-tubes and sutures will depend 
upon the character of the wound. Sutures cannot often be 
used with advantage if much retraction of the skin has 
occurred, and a draiu age-tube is not required if the wound 
is left open. A piece of protective is next applied over the 
surface of the wound, and the deep gauze dressing, wrung 
out in a 1 : 2000 bichloride solution, is applied over this, 
and the superficial gauze dressing and bichloride cotton are 
next applied and secured by a bandage. 

Infected wounds which are treated in this manner will 
often be rendered aseptic, and in their subsequent course 
will be perfectly satisfactory, both to the patient and to the 
surgeon. 



Materials Used in Surgical Dressings — Cvntinued. 
Lixt. 

This material is employed in surgical dressings, and is of 
two varieties : the domestic lint, which consists of pieces of 
old linen or muslin which have been thoroughly washed or 
boiled and then dried, or the surgical lint which is manu- 
factured by machinery, and resembles Canton flannel in 
appearance ; the latter is the best material, as it has a greater 
absorbing capacity. 

Lint is used as a material on which unctuous preparations 
are spread in the dressing of wounds, and is also employed 
as a material for saturating with the various solutions which 
are used in wet dressings, such as lead-water and laudanum, 
or dilute alcohol ; the lint, after being saturated with these 
solutions, is covered with rubber tissue or oiled silk when 



130 MINOE SURGERY. 

applied, to prevent too rapid evaporation of the solution. 
It is also one of the best materials from which to construct 
compresses employed in the treatment of fractures, to control 
hemorrhage, or to make pressure for any purpose 

Paper-lint, made from old rags or wood pulp, has great 
absorbing power for fluids, and may be used as a substitute 
for surgical lint in the application of wet dressings to sur- 
faces when the skin is unbroken. 

Oakum. 

This material, made from old tarred rope, was formerly 
much employed in the dressing of wounds before the intro- 
duction of the antiseptic method of wound-treatment; it was 
supposed to possess some antiseptic properties due to the tar 
with which it was impregnated. From its elasticity it is 
found to be an excellent material for padding splints or 
other surgical appliances. It is also employed in the form 
of pads to place under patients to relieve portions of the 
body from pressure, or to absorb discharges which soak 
through the dressings. A mass of oakum which has been 
well teased out and wrapped in a towel forms an excellent 
pillow on which to support a stump. The oakum seton is 
highly recommended by Dr. Sayre as a means of making a 
direct application of ointments to sinuses of bone ; the oakum 
is loosely twisted into a cord and covered with any ointment 
desired and is passed through the sinuses in the bone ; the 
position of the seton is changed from time to time, fresh 
ointment being applied before it is drawn through ; resin 
•cerate is a favorite application to these sinuses made in this 
manner. 

Cotton. 

Cotton is now employed in surgical dressings principally 
as a material to pad splints or to relieve salient parts of the 
skeleton from pressure in the application of splints or ban- 
dages; for instance, in the application of the plaster- of- Paris 
bandages, the bony prominences are generally covered by 



OILED SILK OR MUSLIN. 131 

small masses of cotton ; it possesses but little absorbent 
power unless used in the form of absorbent cotton, and is not 
much employed in surgical dressings, except for the purposes 
mentioned above. 

Absorbent Cotton. 

This material is prepared from ordinary cotton, which is 
boiled with a strong alkali to remove the oily matter which 
it contains. When so prepared it absorbs liquids freely, and 
by reason of its great absorbing capacity it is largely employed 
in surgical dressings. A small mass of absorbent cotton 
wrapped upon the end of a probe or stick is now generally 
employed to make applications to wounds, and has taken 
the place of the sponge or brush which was formerly em- 
ployed for this purpose. From its cheapness, after one 
application it can be thrown away and a new piece can be 
used, and thus the danger of carrying infection from one 
wound to another by the applicator is abolished. It is 
largely employed in gynecological practice for making appli- 
cations to the female genital organs. 

It is impregnated with various antiseptic substances, such 
as the bichloride of mercury, carbolic acid, boric acid, and 
salicylic acid, and, when thus treated, forms the bichloride, 
carbolized, borated, and salicylated cotton so much employed 
in antiseptic dressings. 

Jute. 

This substance is made from the fibre of the Corchorus 
capsularis, which, on account of the character of its fibre, 
possesses both elasticity and absorbing qualities; it has been 
employed for much the same purposes as oakum and cotton, 
such as the padding of splints, and is also used as an external 
absorbing dressing. 

Oiled Silk ob Muslin. 

These materials are employed as an external cover for 
moist dressings to prevent rapid evaporation from the dress- 



132 MINOR SURGERY. 

ings ; they form excellent materials for this purpose, but as 
they are quite expensive their use is limited. 

Waxed or Paraffine Paper. 

This dressing is prepared by passing sheets of tissue-paper 
through melted wax or paraffine, and then allowing them to 
dry for a few minutes. Paper thus treated forms an excel- 
lent and cheap substitute for oiled silk or muslin, and may 
be employed for the same purpose for which the latter 
materials are used. 

Rubber Tissue. 

This material, which is prepared by rubber manufacturers, 
consists of rubber run out into very thin sheets ; it has a 
glazed surface, is very pliable and strong at the same time, 
and forms a cheap and satisfactory substitute for oiled silk, 
and is employed for the same purposes. In the moist method 
of antiseptic dressing it may be used in place of the mack- 
intosh, and indeed I prefer it to the latter in this method of 
dressing. 

Parchment Paper. 

This paper is prepared so as to render it water-proof; it 
is employed in surgical dressings for the same purposes as 
oiled silk and rubber tissue. 

Compresses. 

Compresses are prepared by folding pieces of lint, muslin, 
linen, or flannel upon themselves so as to form firm masses 
of variable sizes ; oakum or cotton may also be used to form 
compresses. Compresses are employed to make pressure 
over localized portions of the body, as in the treatment of 
fractures, or to make pressure upon vessels for the control 
of hemorrhage. 



RETRACTORS. 



138 



Tent. 

This consists of a small portion of lint, oakum, or muslin 
rolled in a conical shape, which is employed to keep wounds 
open and facilitate discharges. This dressing is not much 
employed at the present time, its use being largely super- 
seded by the drainage-tube. 

Retractors. 

Retractors are made by taking a piece of muslin four 
inches wide and twelve to eighteen inches in length and 



Fig. 86. 



Fig. 87. 






Two-tailed retractor. 



Three-tailed retractor. 



splitting it as far as the centre, thus making a two-tailed 
retractor. (Fig. 86.) A three-tailed retractor is made in 



134 MINOR SURGERY. 

the same way, except that the muslin is slit twice instead of 
once. (Fig. 87.) Retractors are used to retract the soft 
parts in amputation, to prevent their injury by the saw in 
the division of the bones. When one bone is sawed a two- 
tailed retractor is used, and when two bones are sawed a 
three-tailed retractor is employed. 

Plasters. 

The varieties of plaster which are most commonly em- 
ployed in surgical dressings are adhesive or resin plaster, 
isinglass plaster and rubber adhesive plaster. 

Resin Plaster. — This plaster, which is machine-spread, 
is one of the most widely employed plasters in surgical 
dressings ; the spread surface is covered with a layer of 
tissue-paper, which should be removed before it is used ; it 
is cut into strips of the required width and length, and the 
strips should be cut lengthwise from the roll of plaster, as 
the cloth upon which it is spread stretches more transversely 
than in a longitudinal direction. When heated and applied 
to the surface it holds firmly ; it is prepared for application 
by applying the unspread side to a vessel containing hot 
water, or it may be passed rapidly through the flame of an 
alcohol lamp. 

This is the variety of plaster which is generally used in 
making the extension apparatus for the treatment of frac- 
tures, for strapping the chest in fractures of the ribs and 
sternum, for strapping the pelvis in cases of fractures of 
the pelvic bones, or for strapping the breast, the testicle, 
ulcers, or joints. 

Rubber Adhesive Plaster is made by spreading a prepa- 
ration of India-rubber on muslin, and has the advantage 
over the ordinary resin plaster that it adheres without 
the application of heat. It is employed for the same pur- 
poses as resin plaster, but when applied directly to the skin 
it is apt to produce a certain amount of irritation, and for 
this reason when it is to be continuously applied for some 



PLASTERS. 135 

time, as in the case of an extension apparatus, it is not so 
comfortable a dressing as that made from resin plaster. 

Isinglass Plaster, which is made by spreading a solu- 
tion of isinglass upou silk or muslin, will be found to be a 
most useful dressing in the treatment of superficial wounds. 
It is made to adhere to the surface by moistening it, and 
when used in the treatment of wounds it should be moistened 
with an antiseptic solution ; it is in this way rendered anti- 
septic and may be used with safety in connection with other 
antiseptic dressings. The best form of this plaster is spread 
on muslin, and when properly applied adheres as firmly and 
possesses as much strength as the ordinary resin plaster. 

Before using any of these plasters, if the part to which 
they are to be applied contains hairs, these should be shaved 
off, otherwise traction upon these, if the plaster is used for 
the purpose of extension, or in its removal, will cause the 
patient discomfort or pain. 

Soap Plaster. — Soap plaster for surgical purposes is 
prepared by spreading emplastrum saponis upon kid or 
chamois. It is not employed for the same purposes as the 
resin or rubber plaster, as it has little adhesive power, and 
is used simply to give support to parts or to protect salient 
portions of the skeleton from pressure. It is found a most 
useful dressing when applied over the sacrum in cases of 
threatened bedsores, and may be applied for the same pur- 
pose to other parts of the body where pressure sores are apt 
to occur. 

In the treatment of sprains of joints a well-moulded soap- 
plaster splint secured by a bandage will often be found a 
most efficient dressing, and in the treatment of fractures the 
comfort of the patient is often materially increased by apply- 
ing small pieces of soap plaster over the bony prominences, 
upon which the splints, even when well padded, are apt to 
make an undue amount of pressure. 

Strapping, or applying pressure to parts by means of 
strips of plaster firmly applied, is a procedure often employed 
in surgical practice. 



136 MINOR SURGERY. 



Strapping the Testicle. 

In strapping the testicle strips of resin plaster are usually- 
employed ; a dozen or more strips one-half an inch wide and 
twelve inches in length will be required. 

The scrotum should be first washed and shaved, and the 
surgeon next draws the skin over the affected organ tense 
by passing the thumb and finger around the scrotum at its 
upper portion, making circular constriction ; a strip of 
plaster which has been heated is passed in a circular manner 
around the skin of the scrotum above the organ, and is 
tightly drawn and secured ; this isolates the part and pre- 
vents the other strips from slipping. Strips are now applied 
in a longitudinal direction, the first strip being fastened to 

Fig. 88. 





Strapping the testicle. (Smith.) 

the circular strip and carried over the most prominent part 
of the testicle, and is then carried back to the circular strip 
and fastened. A number of these strips are applied in an 
imbricated manner until the skin is covered (Fig. 88), and 
the dressing is completed by passing transverse strips around 
the testicle from its lowest portion to the circular strip; 
care should be taken to see that no portion of the skin is 
left uncovered. 

Strapping the testicle is employed with advantage in the 
subacute stage of orchitis or epididymitis, and it will be 
found a useful means of applying pressure to the scrotum 
after the injection treatment of hydrocele. As the swelling 
of the testicle diminishes the strips become loose, and the 
part will require re- strapping. 



STRAPPING THE CHEST. 



137 



Strapping of the Breast. 



To strap the breast, strips of resin plaster two inches wide 
and long enough to pass from the opposite shoulder under 
the breast to the point of starting are required. In applying 
the strips the end of the strip is placed on the spine 
of the scapula of the side opposite the diseased breast 
and is carried forward over the shoulder and obliquely down- 
ward under the breast and axilla, and then over the back to 
the point of starting ; the first strip being applied in this 
manner, the next one is applied in the same direction, over- 
lapping about one-third of 
the previous strip (Fig. 89). Fia 89 - 

These oblique strips are ap- 
plied in an imbricated manner 
until a sufficient number have 
been used to cover in the 
breast, or the oblique strips 
may be alternated with cir- 
cular strips passing from the 
sternum over the breast to 
the spine. A sufficient num- 
ber of strips are used to 
cover the breast and to make 
firm compression upon it. Strapping of the breast in this 
manner will be found a satisfactory method of treatment in 
chronic inflammatory conditions of the breast, where it is of 
advantage to support the breast and make compression at 
the same time ; it has the advantage over the use of a ban- 
dage to support and compress the breast, that it does not 
interfere with the chest motions upon the opposite side of 
the body. 

Strapping of the Chest. 




Strapping the breast. 



(Smith.) 



To strap one-half of the chest, strips of resin plaster two 

inches wide, and long enough to extend from the 

spine to the median line of the sternum are required — eighteen 

to twenty inches in length. The first strip is heated and one 




138 MINOR SURGERY. 

extremity is placed upon the spine opposite the lower portion 
of the chest ; it is then carried over the chest and its other 
extremity is fixed upon the skin in the median line of the 
sternum. Strips are next applied from below upward in 
the same manner, each strip overlapping one-third of the 
preceding one, until the axillary fold 
FlG - 90 - is reached (Fig. 90) ; a second layer 

of strips may be applied over the 
first, if additional fixation is desired, 
or a few oblique strips may be em- 
ployed. 

Adhesive straps applied in this 

manner very materially limit the 

motion of the chest-wall upon the 

affected side, and are frequently 

£ fM employed in the treatment of frac- 

strapping of the chest. tures and dislocations of the ribs, in 

contusions of the chest, and in cases 

of plastic pleurisy when the motions of the chest-walls are 

extremely painful to the patient. 

Strapping of Ulcers. 

To strap ulcers of the leg, strips of resin plaster one and 
a half inches wide, and long enough to extend two- thirds 
around the limb, are required. The ulcer should be thor- 
oughly cleansed, and the skin surrounding it should be well 
dried ; the first strip, being heated, is applied obliquely to 
the long axis of the leg about two inches below the ulcer, 
and is carried two-thirds around the limb ; another strip is 
applied to a corresponding point of the skin on the opposite 
side of the limb, and is carried obliquely over the limb, 
crossing the first strip in the median line, and is carried two- 
thirds of the way around the limb ; alternate strips are thus 
applied until the ulcer is covered in, and the strips are car- 
ried several inches above the ulcer (Fig. 91). Care should 
be taken to see that the strips are so applied as not to meet 
or cover the entire circumference of the limb, as by so doing 
injurious circular compression may result. Chronic ulcers 



STRAPPING OF JOINTS. 139 

upon other portions of the body may be strapped in the 
same manner. 

Strapping of leg ulcers is usually reinforced by the appli- 
cation of a firmly applied spiral reversed or spica bandage 
of the lower extremity. 

Fig. 91. 




Strapping of ulcer of leg. (Listor.) 

Strapping of ulcers of the leg applied in the manner 
described will be found a most satisfactory method of treating 
chronic ulcers in this location in patients who have to work 
during the course of treatment ; the strips need only be 
removed at intervals of a week, and, if well applied, the 
dressing is generally a comfortable one to the patient. 

Strapping of Joints. 

Strips of resin plaster two inches in width and long 
enough to extend two-thirds around the joint are required. 
The first strip is applied a few inches below the joint, and 
strips are then applied, over this, each strip covering in two- 



140 MINOR SURGERY. 

thirds of the preceding one until the joint is covered in and 
the strips extend a few inches above the joint. 

The ankle-joint is strapped by taking strips of resin 
plaster one inch in width ; the first strip is placed over the 
heel, and its ends are brought forward until they meet over 
the dorsum of the foot ; a second strip encircles the foot 
and secures the ends of the first strip. These strips are 
alternately applied, each strip covering in one-half of the 
previous strip until the foot and ankle are covered in. 

Strapping of joints will be found a satisfactory dressing 
in the treatment of sprains of joints in their chronic state. 

Strapping of a Carbuncle. 

To strap a carbuncle strips of resin plaster one to one and 
a half inches in width are required ; these strips are applied 
at the margin of the swelling and are laid on concentrically 
until all except the central portion is covered. If a number 
of openings exist, the strips are so placed as not to cover 
these. Strapping applied in this manner in the treatment 
of carbuncle is often a comfortable dressing for the patient, 
and at the same time the concentric pressure favors the 
extrusion of the slough. 

Poultices. 

This form of dressing was formerly much employed in 
the treatment of inflammatory conditions and injuries as a 
means of applying heat and moisture to the part at the 
same time, and although the use of poultices is now very 
much restricted since the introduction of the antiseptic 
method of wound treatment, yet I think there are still 
conditions in which their employment is both useful and 
judicious. 

They are often employed with advantage in inflammatory 
affections of the chest and of the abdominal organs, and in 
inflammatory affections of the joints and of bone, combined 
with rest, their action is often most satisfactory ; in cases of 



POULTICES. 141 

gangrene their employment hastens the separation of the 
sloughs. 

They constitute a form of dressing which conduces much 
to the comfort of the patient in cases of deep suppuration 
by their relaxing effect upon the tissues, and their previous 
use does not prevent the surgeon from using all antiseptic 
precautions in the opening and drainage of these abscesses 
and the employment of antiseptic dressing in their subse- 
quent treatment. 

Flaxseed Poultice. 

This poultice is prepared by adding first a little cold 
water to ground flaxseed and then adding boiling water, 
and stirring it in until the resulting mixture is of the con- 
sistency of thick mush. A piece of muslin is next taken 
which is a little larger than the intended poultice, and 
this is laid upon the surface of a table and the poultice 
mass is spread evenly upon it with a spatula or knife 
from one-quarter to one-half an inch in thickness ; a margin 
of the muslin of one or one and a half inches is left, 
which is turned over after the poultice is spread, and 
serves to prevent it from escaping around the edges when 
applied. The surface of the poultice may be thinly spread 
over with a little olive oil, or may be covered with a layer 
of thin gauze to prevent the mass from adhering to the 
skin. 

It is now applied to the surface of the skin and is covered 
with a piece of oiled silk, rubber tissue, or waxed paper, and 
held in position by a bandage or a binder. 

Bread Poultice. 

This poultice is prepared from stale wheaten bread, the 
crusts being discarded and the crumb only being used ; this 
is moistened with boiling water and allowed to soak for a 
few minutes, when the excess of water is poured off and the 
mass is spread upon a piece of muslin or linen, as before 
described. 



142 MINOR SURGERY. 



Charcoal Poultice. 



In preparing this poultice flaxseed-meal and powdered char- 
coal in equal parts are mixed together, and by adding boiling 
water a poultice mass is produced, which is spread upon 
muslin, as previously detailed. It is better to use animal 
charcoal in making this poultice, as it possesses greater dis- 
infecting power than vegetable charcoal. This poultice is 
used as an application to gangrenous parts, as it possesses 
marked disinfecting properties. 

Fermenting Poultice. 

This poultice may be prepared by adding yeast, two table- 
spoonfuls, to a mixture of flaxseed with hot water, making a 
thin poultice mass, and allowing it to stand for a few hours 
in a warm place ; it rises and becomes light, and is then 
spread upon muslin and applied as required. A few ounces 
of porter or a piece of yeast cake may be used as a substi- 
tute for the yeast in preparing this poultice ; charcoal may 
also be added to it to increase its disinfectant power. This 
poultice was formerly and is still used as an application to 
gangrenous parts to hasten their separation and to diminish 
the odor arising from the necrotic tissues. 

Oakum Poultice. 

This is prepared by soaking a mass of loosely picked 
oakum in hot water, wringing it out and covering it with a 
layer of cheese-cloth or antiseptic gauze. It is next applied 
to the part and covered with oiled silk or rubber tissue, and 
held in place by a bandage : it has a large capacity for the 
absorption of discharges. 

It may be wrung out in a warm bichloride solution, or 
carbolic solution, and thus form an antiseptic poultice. 

Hot Fomentations. 

Hot fomentations are employed to keep up the vitality of 
parts which have been subjected to injury, as seen in severe 



IRRIGATION. 143 

contusions resulting from railway or machinery accidents ; 
also to combat inflammatory action. Flannel cloths, several 
layers in thickness, or surgical lint should be soaked in water 
having a temperature of 120° ; these are wrung out and 
placed over the part and covered with waxed paper or rubber 
tissue ; a second cloth should be in the hot water, ready to 
apply as soon as the first-applied cloth begins to cool, and so 
by continuously reapplying them the part is kept constantly 
covered by a hot dressing. The use of these hot fomenta- 
tions may in many cases have to be continued for hours 
before the desired result is obtained. Hot compresses 
applied in this manner are frequently employed in treating in- 
flammatory conditions of the eye, and are also of the greatest 
service in keeping up the vitality of parts which have been 
subjected to severe injury interfering with their blood- 
supply. I have seen contused limbs, which were cold and 
seemed to be doomed to gangrene by reason of diminished 
blood-supply, have their temperature and circulation restored 
by the patient and persistent use of this dressing. After 
the vitality of such a part is restored it should be covered 
with cotton and a flannel bandage and surrounded by hot- 
water bass or hot- water cans. 



Irrigation. 

This may be accomplished by allowing the irrigating fluid 
to come in contact with the wound or inflamed part, or by 
allowing the cold or warm fluids to pass through rubber 
tubes which are in contact with or surround the part ; the 
latter method is known as mediate irrigation. 

In employing irrigation in the treatment of wounds or in 
inflammatory conditions, a funnel-shaped can with a stop- 
cock at the bottom, or a bucket is suspended over the part at 
a distance of a few inches (Fig. 92), or ajar with a skein of 
thread or lamp-wick arranged to act as a siphon may be em- 
ployed. (Fig. 93.) The can or jar is filled with water, and 
this is allowed to fall drop by drop upon the part to be irri- 
gated, which should be placed upon a piece of rubber sheeting 



144 



MINOR SURGERY 



so arranged as to allow the water to run off into a re- 
ceptacle so as to prevent the wetting of the patient's bed. 
The water employed may be either cold or warm, and this 
is decided by the indications in special cases, and if it is 



Fig. 92. 




Apparatus for continuous irrigation. (Esmarch.) 

desired to make use of antiseptic irrigation the water is 
impregnated with carbolic acid or bichloride of mercury ; a 
1:5000 to 1:10,000 bichloride solution, or a 1 : 60 car- 
bolic acid solution, is frequently employed with good re- 
sults. 

Antiseptic irrigation employed in this manner will be 
found a most useful method of treating lacerated and con- 



IRRIGATION. 145 

tused wounds of the extremities in which the vitality of 
the tissues is much impaired ; and in such cases . the warm 
water should be preferred to cool water, the temperature 
being from 100° to 110°. 

Fig. 93. 



Irrigating apparatus. (Erichsen.) 

Under the use of warm irrigation it is surprising to see 
how tissues apparently devitalized regain their vitality ; the 
absence of tension from the non-introduction of sutures and 
firm dressings, and the warmth and moisture kept constantly 
in contact with the wound by this method of irrigation, are 
the important factors in the attainment of this favorable 
result. 

Mediate Irrigation. 

In this method cold or warm irrigation is applied to the 
part by means of cold or warm water passing through a 
rubber tube in contact with the part. A flexible tube of 
India-rubber half an inch in diameter, with thin walls, and 
sixteen or twenty feet in length, is applied to the limb like 
a spiral bandage, or is applied in a coil to the head, breast, 
or joints and held in place by a few turns of a bandage ; 
the end of the tube is attached to a reservoir filled with cold 
or warm water above the level of the patient's body, and 



146 



MINOR SURGERY 



the water is allowed to flow constantly through the tubing 
and escape into a receptacle arranged to receive it. (Fig. 
94.) 



Fig. 94. 




Cold coil applied to arm. (Esmarch.) 



Cold Water Dressings. 



These dressings are applied by bringing the cold water 
either directly in contact with the part or by applying it by 
means of a rubber bag or bladder. 

The temperature of the water may vary from cool water 
to that of ice-water. 

These dressings are employed in local inflammatory con- 
ditions ; a favorite method of employment of this dressing 
is by means of cold compresses, which are made of a few 
layers of surgical lint, dipped in water of the desired tem- 
perature and applied to the part ; they are renewed as 
soon as they become warm. When it is desirable to have 
the compresses very cold, they may be laid upon a block 
of ice or in a basin with broken ice; to obtain the best 



RUBEFACIENTS. 147 

results from their employment they should be renewed at 
very short intervals. 

A convenient method of applying cold without moisture 
is by the use of the ice-bag. This is either a rubber bag 
or bladder, which is filled with broken ice and applied to 
the part. In using an ice-bag it is better to cover the part 
first with a towel or a few layers of lint or muslin, which 
prevents the surface from becoming wet by absorbing the 
moisture which condenses upon the surface of the bag or 
bladder, and thus renders the dressing more comfortable to 
the patient. The ice-bag is often employed as an applica- 
tion to the head in inflammatory conditions of the brain or 
membranes, and is also used upon the surface of the body 
to control internal hemorrhage. 

Counter-irritation. 

Counter-irritants are substances employed to excite ex- 
ternal irritation, and the extent of their action varies ac- 
cording to the material used and duration of its application ; 
superficial redness or complete destruction of the vitality of 
the parts to which they are applied may result. 

The use of counter-irritants under favorable circumstances 
is found to have a decided effect in modifying morbid pro- 
cesses, and they are widely employed as local revulsants in 
cases of congestion or inflammation, and in cases of collapse 
for their stimulating effect. 



Rubefacients. 

These agents, by reason of their irritating properties 
■when applied to the skin, produce intense redness and con- 
gestion. 

Hot Water. — When it is desired to make a quick im- 
pression upon the skin, the application of muslin or flannel 
cloths wrung out in hot water and renewed as rapidly as 
they become cool will soon produce a superficial redness of 
the integuments. 



148 MINOR SURGERY. 

Spirits of Turpentine. — This drug applied to the skin is 
a very active counter-irritant ; it may be rubbed upon the 
surface of the skin until redness results. When used in 
patients whose skin is very delicate, its action may be modi- 
fied by mixing it with equal parts of olive oil before apply- 
ing it ; this will be found a useful precaution in applying it 
as a rubefacient to the tender skins of young children. 

When redness of the skin has resulted from the applica- 
tion, the skin should be wiped dry by means of a soft towel 
or absorbent cotton to remove any turpentine from the 
surface, which by its continued contact may cause vesi- 
cation. 

Turpentine is often employed as a rubefacient in the form of 
the turpentine stupe, which is prepared by sprinkling spirits 
of turpentine over flannel cloths which have been wrung 
out in hot water, or by dipping hot flannel in warm spirits 
of turpentine ; prepared in either way the stupe should be 
squeezed as dry as possible to remove the excess of tur- 
pentine before being applied to the surface of the body. A 
turpentine stupe may cause vesication if allowed to remain 
for too long a time in contact with the skin ; its application 
for from five to ten minutes will usually produce the desired 
effect ; it should be removed after this time, and it can be 
reapplied if desired. 

If the patient complains of severe burning of the skin 
after the use of turpentine, the painful surface should be 
freely smeared with vaseline or lard, which will relieve the 
uncomfortable symptom. 

Chloroform. — A few drops of chloroform applied to the 
surface of the body by means of a piece of lint, muslin, or 
flannel, and covered by oiled silk or rubber tissue, will excite 
a rapid rubefacient effect. 

Mustard. — Ground mustard or mustard flour prepared 
from either Sinapis alba or Sindpis nigra is one of the most 
commonly used substances to produre rubefacient action. 
It is generally employed in the form of the mustard plaster 
or sinapism, which is prepared by mixing equal parts of 
mustard flour with wheat flour or flaxseed meal, and adding 
to this enough warm water to make a thick paste ; this is 



RUBEFACIENTS. 149 

spread upon a piece of old muslin, and the surface of the 
paste should be covered with some thin material, such as 
gauze, to prevent the paste from adhering to the skin. In 
making a mustard plaster for application to the tender skin 
of a child, 1 part of mustard flour should be mixed with 3 
parts of wheat flour or flaxseed meal. 

A mustard plaster or sinapism may be allowed to remain 
in contact with the skin for a period varying from fifteen to 
thirty minutes, the time being governed by the sensations of 
the patient ; if it is allowed to remain longer it may cause 
vesication, which is to be avoided, as ulcers produced by 
mustard are very painful and extremely slow in healing. 
After removing a sinapism the irritated surface of the skin 
should be dressed with a piece of muslin or lint spread with 
vaseline, boric acid or oxide of zinc ointment. 

To excite a rapid revulsive action the mustard foot-bath is 
often employed : it is prepared by adding two tablespoonfuls 
of mustard flour to a bucket or foot-tub of water at a tem- 
perature of 100° to 110° ; in this the patient is allowed to 
soak his feet for a few minutes. 

Mustard Papers — Charta Sinapis, which can be obtained 
in the shops ready for use, are a convenient means of obtain- 
ing the rubefacient action of mustard. They are dipped in 
warm water, and as they are generally very strong, it is well 
to place a layer of muslin between the surface of the plaster 
and the skin before applying it to the surface. 

Capsicum or Cayenne pepper is also sometimes employed 
as a rubefacient, but it is generally employed in combination 
with spices, forming the well-known spice plaster ; this is 
prepared by taking equal parts of ground ginger, cloves, 
cinnamon, and allspice, and adding to them one-fourth part 
of Cayenne pepper ; these are thoroughly mixed, enclosed in 
a flannel bag, and evenly distributed ; a few stitches should 
be passed through the bag at different points, to prevent the 
powder from shifting its position ; before applying it, one 
side of the bag should be wet with warm whiskey or alcohol. 
Capsine plasters are also employed to obtain the rubefacient 
effect of Cayenne pepper. 

Aqua ammonia may also be employed for its rubefacient 



150 MINOR SURGERY. 

action. A piece of lint saturated with the stronger water of 
ammonia, placed upon the skin and covered with waxed 
paper, and allowed to remain for one or two minutes, will 
produce a marked rubefacient eifect. 

Caution should be exercised in applying counter-irritants 
to patients who are comatose or under the influence of a nar- 
cotic, for here the sensations of a patient cannot be used as 
a guide to their removal, and their too long continued appli- 
cation when the vitality of the tissues is impaired may result 
in serious consequences. 

Vesicants. 

Where it is desirable to make a more permanent counter- 
irritant effect than that produced by rubefacients, substances 
are employed which by their action on the skin cause an 
effusion of serum, or of serum and lymph, beneath the 
cuticle, thus giving rise to vesicles or blisters ; they are 
known as vesicants. 

The substance most commonly employed to produce 
vesication is Cantharis, or Spanish fly, and the preparation 
commonly used is the Qeratum cantharidis, which is spread 
upon adhesive plaster, leaving a margin one-half an inch in 
width uncovered, which will adhere to the skin and hold the 
blister in position. The time required for a fly blister to 
produce vesication is from four to six hours ; it should then 
be removed and the surface should be covered with a flax- 
seed-meal poultice, or with a warm water dressing. When 
the blister or vesicle is well developed, it may be punctured 
at its most dependent part, to allow the serum to escape, and 
it should be dressed with vaseline or boric ointment. If, 
for any reason it is desired to keep up continued irritation, 
after allowing the serum to escape, the cuticle should be cut 
away and the raw surface should be dressed with some 
stimulating material, such as the compound resin cerate. 

Cantharidal Collodion may also be employed to produce 
vesication ; it is applied by painting several layers upon the 
skin with a brush over the part on which the blister is to be 
produced. It is a convenient preparation to use when the 



VESICANTS. 151 

patient would disturb the ordinary blister, as in the case of 
an insane patient, or where the surface is so irregular that 
the ordinary blister cannot be well applied. The after- 
treatment of blisters produced by cantharidal collodion is 
similar to that previously described. 

In the treatment of chronic inflammation it is often 
better to apply a number of small blisters at intervals 
than one large blister producing an extensive vesication 
of the surface. Caution should be observed in using blis- 
ters upon the tender skins of children ; if employed, they 
should be allowed to remain in contact with the skin for a 
short time only. They are contra-indicated in patients in 
whom the vitality of the tissues is depressed by adynamic 
diseases, and in aged persons. 

A complication which sometimes occurs from the use of 
cantharidal preparations as blisters is strangury, which is 
shown by frequent and painful micturition, the urine often 
containing blood. This accident should be treated by the 
use of opium and belladonna by suppository, demulcent 
drinks, and warm sitz-baths, and by leeches to the peri- 
neum if the symptoms are very severe. 

To avoid the development of strangury small blisters 
should be employed, and should not be allowed to remain 
too long in contact with the surface, and cantharidal prepa- 
rations should not be employed in cases where renal or 
vesical irritation has existed or is present. It is said that 
strangury may also be avoided by incorporating opium and 
camphor with the cantharidal cerate. 

Aqua ammonia fortior and chloroform may be employed 
to produce rapid vesication, a few drops being placed upon 
the surface of the body and covered by an inverted watch- 
glass for a few minutes, or lint saturated with aqua ammonia 
or chloroform may be placed upon the skin and covered with 
waxed paper or oiled silk. ■ Either of these agents applied 
in this manner, and allowed to remain in contact with the 
skin for fifteen minutes, will produce marked vesication. 
The blisters resulting from these agents are painful, and 
they are only used where a rapid result is desired. 

Nitrate of silver, in a strong solution or in the form of 



152 



MINOR SURGERY 



the solid stick, may be applied to the surface of the skin to 
produce a counter-irritant effect. Nitrate of silver, applied 
by drawing the moist stick across the skin of the scrotum 
at a number of points, was formerly a popular form of treat- 
ment for acute epididymitis. 

Acupuncture. 



Counter-irritation is effected by this method by thrusting 
steel needles deeply into the subcutaneous tissues. The 
needles employed should be of steel , from 
Fig. 95. two to four inches in length, strong, 

highly polished, and sharp-pointed, and 
should have round metallic heads or be 
fixed in handles. (Fig. 95.) Before being 
used they should be allowed to remain for 
a few minutes in boiling water or in a 
carbolized solution to thoroughly sterilize 
them. In performing the operation of 
acupuncture, localities containing impor- 
tant organs, large bloodvessels, the joints, 
and viscera, should be avoided. When 
introduced the needles should be passed 
through the skin with a rotary motion, 
the skin being rendered tense between 
the thumb and fingers, and pushed into 
the deep-seated structures. They are 
allowed to remain in position for a few 
moments and are then withdrawn, the 
skin being supported by the thumb and 
fingers. 
Acupuncture has been found of service in cases of deep- 
seated neuralgia, obstinate rheumatic affections, and sciatica. 



Acupuncture 
needles. 



Issues. 



Issues are ulcers made intentionally by the application of 
caustics, the moxa, or the knife. They are not often em- 



issues. 153 

ployed at the present time, but were formerly a popular 

means of causing long- continued counter-irritation. In 

making an issue, a region was selected where the Subcla- 
ss ' c3 

neous cellular tissue was abundant, and which was free from 
large bloodvessels and nerves, and not near the joints. The 
plan usually adopted was to apply over the surface of the 
skin a piece of adhesive plaster perforated in the centre. A 
small piece of caustic potash or Vienna caustic, mixed with 
water to make it a paste, was placed in the hole in the adhe- 
sive plaster, and held in position by a strip of adhesive 
plaster. In one or two hours the plaster should be removed 
and the part should be washed with dilute acid to prevent 
further action of the caustic ; a poultice of flaxseed should 
next be applied, to hasten the separation of the slough. 
The ulcer remaining after the removal of the slough may be 
kept from healing by introducing into it a small wooden 
ball known as an issue pea, or a glass bead or pebble held 
in place by a compress and adhesive strap. 

The Moxa was formerly used to make an issue ; it con- 
sisted of a small mass of some combustible material, such as 
punk, cotton, or lint, rolled into pyramidal 
shape, which was placed upon the surface of the Fig. 9fi. 
body and ignited so as to produce an eschar jff^ 

upon the skin. To facilitate the application of 
the moxa an instrument called the porte-moxa 
(Fig. 96) is employed. The treatment of the 
eschar resulting from the moxa is the same as 
that resulting from the use of caustic potash. 

The knife was also employed to establish an 
issue, a crucial incision being made through the 
skin and cellular tissues into the deep tissues ; 
the objection to the use of the knife in forming 
an issue was the difficulty in preventing the 
wound from healing. 

The Seton. — A seton is a subcutaneous sinus, 
or an issue with two openings upon the surface, Porte-moxa. 
which is prevented from healing by the intro- 
duction of a foreign body. It is established by introducing 
a few strands of silk, a narrow strip of linen, or a rubber 



154 



MINOR SURGERY. 



ligature, by means of a seton-needle (Fig. 97), or by means 
of a sharp-pointed bistoury and an eyed probe. The seton- 



Fig. 97. 




Seton-needle. 



needle should be passed deeply into the superficial fascia, 
care being taken to avoid important veins and nerves. 

A seton may also be established by pinching up a fold of 
skin and transfixing its base with a narrow, sharp-pointed 
bistoury (Fig. 98), and passing through the wound thus 



Fig. 98. 




'Method of forming a seton. 



made an eyed probe armed with a few strands of silk, a strip 
of muslin, or an elastic ligature ; the probe is then removed 
and the ends loosely tied together. The wound should be 
dressed, and at each change of the dressing the strip should 
be removed, or it may be smeared with some stimulating 



ACTUAL CAUTERY. 



155 



ointment, which can thus be brought in contact with the 
granulating surface by drawing it through the wound. 

Actual Cautery. 

This method of counter-irritation is accomplished by 
brinorinor in contact with the skin some metallic substance 
brought to a high degree of temperature. This constitutes 
one of the most powerful means of counter-irritation and 
revulsion ; it is rapid in its action, and is not more painful 
than some of the slower methods. The cauteries generally 
employed are made of iron, and are fixed in handles of wood 
or other non-conducting material, and have their extremities 
fashioned in a variety of shapes (Fig. 99). The irons are 




Cautery irons. 

heated by placing their extremities in an ordinary fire, or 
by holding them in the flame of a spirit-lamp until they are 
heated to the desired point, either white or dull-red heat. 
They are then applied to the surface of the skin at one point, 
or drawn over the skin in lines either parallel to or crossing 
one another. The intense burning which follows the use of 
the cautery may be allayed by placing upon the cautery- 
marks compresses wrung out in ice-water or saturated with 
equal parts of lime-water and sweet oil. 

Where the ordinary cautery irons are not at hand, a steel 
knitting-needle or iron poker heated in the flame of a spirit- 



156 



MINOR SURGERY. 



lamp or in a fire may be employed with equally satisfactory 
results. Where the cautery iron is held in contact with the 
surface for some time to make a deep burn, the pain of its 
application may be allayed by placing a mixture of salt and 
cracked ice upon the spot to be cauterized for a few minutes 
immediately before its application. The cautery iron should 
not be placed over the skin covering salient parts of the 
skeleton or over important organs. 

Actual cautery thus applied, in addition to its use in pro- 
ducing counter-irritation and revulsion, is often employed 
to control hemorrhage and to destroy morbid growths. 

Paquelin's Thermo-cautery. 

A very convenient and efficient means of using thermo- 
cautery is the apparatus of Paquelin, which utilizes the prop- 
erty of heated platinum-sponge to become incandescent when 




Paquelin's cautery. 



SCARIFICATION. 15? 

exposed to the action of the vapor of benzole or rhigolene. 
(Fig. 100.) The cautery is prepared for use by attaching 
the guin tube to the receiver containing benzole and heating 
the platinum knife or button, which is also attached to the 
benzole receiver by a rubber tube, in the flame of the alcohol 
lamp for a few moments, and then passing the vapor of 
benzole through the platinum-sponge, which is enclosed in 
the knife or button, by compressing the rubber bulb. The 
points may be brought to a high degree of heat, or may be 
Drought only to a dull- red heat. 

This form of cautery may be employed for the same pur- 
poses as that previously mentioned; its great advantage con- 
sists in the ease with which it can be prepared for use. The 
knives heated to a dull-red heat will be found of great 
service in operating upon vascular tumors, where the use of 
an ordinary knife would be accompanied by profuse or even 
dangerous hemorrhage. Wounds made by the actual cautery 
are aseptic wounds, and when dusted with iodoform will 
generally heal promptly under the scab without suppuration. 

Bloodletting. 

This procedure is often resorted-to to obtain both the local 
and the general effects following the withdrawal of blood 
from the circulation. Local depletion is accomplished by 
means of some one of the following procedures : scarifica- 
tion, pun duration, cupping and leeching, and general de- 
pletion is effected by means of venesection or arteriotomy. 

Scarification. 

Scarification is performed by making small and not too 
deep incisions into an inflamed or congested part with a 
sharp-pointed bistoury : the incisions should be in parallel 
lines and should be made to correspond to the long axis of 
the part, and care should be taken in making them to avoid 
wounding superficial veins and nerves. Incisions thus made 
relieve tension by allowing blood and serum to escape from 

8 



158 MINOR SURGERY. 

the engorged capillaries of the infiltrated tissue of the part. 
Warm fomentations applied over the incisions will increase 
and keep up the flow of blood and serum. Scarification is 
employed with advantage in inflammatory conditions of the 
skin and subcutaneous cellular tissue and in acute inflam- 
matory swelling or oedema of the mucous membrane ; for 
instance, of the conjunctiva, and in acute inflammation of 
the tonsils, tongue, and epiglottis it is an especially valuable 
procedure. A modification of scarification known as deep 
incisions is practised in urinary infiltration to establish 
drainage and relieve the tissues of the contained urine and 
to prevent sloughing ; in threatened gangrene and phleg- 
monous erysipelas the same procedure is adopted to relieve 
tension by permitting of the escape of blood and serum, 
and its employment is often followed by most satisfactory 
results. 

PUNCTURATION. 



This procedure consists in making punctures, which should 
not extend deeper than the subcutaneous tissue, into inflamed 
tissues with the point of a sharp-pointed bistoury ; it is an 
operation similar in character to that just described, its 
object being to relieve tension and bring about depletion. 
It is employed in cases similar to those in which scarifica- 
tion is indicated, and is resorted to in cases of diffuse areolar 
inflammation or erysipelas. 

Cupping. 

Cupping is a convenient method of employing local deple- 
tion by inviting the blood from the deeper parts to the surface 
of the skin. Cupping is accomplished by the use of wet or 
dry cups. When the former are used, no blood is abstracted 
and the derivative action only is obtained; when wet cups 
are employed there is an actual abstraction of blood or local 
depletion as well as the derivative action. 



CUPPING 



159 



Dry Cupping. 



Fig. 101. 



Dry cups as ordinarily applied consist of small cup- 
shaped glasses, which have a valve and stop-cock at their 
summit; these are placed upon the skin and an air-pump is 
attached, and as the air is exhausted in the cup the con- 
gested integument is seen to bulge into the cavity of the 
cup. When the exhaustion is complete the stop-cock is 
turned and the air-pump is removed, the cup being allowed 
to remain in position for a few minutes, and is 
then removed by turning the stop-cock and allow- 
ing the air again to enter the cup. This pro- 
cedure is repeated until a sufficient number of 
cups have been applied. 

In cases of emergency, w r hen the ordinary 
cupping-glasses and air-pump cannot be ob- 
tained, a very satisfactory substitute may be 
obtained by taking a wineglass and burning in 
it a little roll of paper, or a small piece of 
lint or paper wet with alcohol, and before the 
flame is extinguished rapidly inverting it upon 
the skin, or the air may be exhausted by the 
introduction, for a moment or two, of the flame 
of a spirit-lamp into the cup. Applied in 
this manner cups will draw as w T ell as when 
the more complicated apparatus is used, and 
when they are removed it is only necessary to 
press the finger on the skin close to the edge 
of the cup until air enters the cup, when it will 
fall off. Although dry cups do not remove blood 
there is often an escape of blood from the capil- 
laries into the skin and cellular tissue, as evidenced by the 
ecchymosis which frequently remains at the seat of the cup- 
marks for some days. 

Dry cups, as previously stated, are employed for their 
derivative action in cases in which depletion is not indi- 
cated. 



Cupping- 
glass and 
air-pump. 



160 



MINOR SURGERY. 



Wet Cupping. 

When the abstraction of blood as well as the derivative 
action is desired wet cups are resorted to, and here it is 
necessary to have a scarificator as well as the cups and air- 
pump. (Fig. 102.) 

Before applying wet cups the skin should be washed care- 
fully with a carbolic solution, and the scarificator should 
also be dipped in a carbolic solu- 
Fig 102. tion. A cup is first applied to pro- 

duce superficial congestion of the 
skin ; this is removed and the 
scarificator is applied, and the skin 
is cut by springing the blades, and 
the cups are immediately applied 
and exhausted, and they are kept 
in place as long as blood continues 
to flow. When the vacuum is ex- 
hausted and blood ceases to flow, 
Scarificator. they should be removed and emptied, 

and can be reapplied if it is de- 
sirable to remove more blood. A sharp-pointed bistoury 
which has been sterilized may be employed to make a few 
incisions into the skin instead of the scarificator, and the 
improvised cups may be employed if the ordinary cupping 
apparatus cannot be obtained. 

After the removal of wet cups the skin should be washed 
carefully with a bichloride or carbolic solution, and an anti- 
septic dressing should be placed over the wounds and held 
in place by a roller bandage. 




Leeching. 



In the abstraction of blood by leeching two varieties of 
leeches are used — the American leech, which draws about 
a teaspoonful of blood, and the Swedish leech, which draws 
three or four teaspoonfuls. 

Before applying leeches the skin should be carefully 



LEECHING 



161 



Fig. 103. 



washed, and the leech should be placed upon the part from 
which the blood is to be drawn, and confined to this place 
by inverting a tumbler or glass jar over him ; if he does not 
bite or take hold, a little milk or blood should be smeared 
upon the surface, which will generally secure the desired 
result. As soon as the leech has ceased to draw blood he 
is apt to let go his hold and fall off; if, however, it is de- 
sired to remove leeches, they may be made to let go their 
hold by sprinkling them with a little salt. After the re- 
moval of leeches bleeding from the bites may be encouraged 
if desirable by the application of warm fomentations. 
Leech-bites should be washed with a bichloride or carbolic 
solution, and a compress of bichloride or iodo- 
form gauze should be placed over them and 
secured by a bandage. 

It sometimes happens that free bleeding 
continues from the leech-bite after the removal 
of the leeches; in this event, if a compress 
does not control the hemorrhage, the bleeding- 
point should be touched with a stick of nitrate 
of silver or with the point of a steel knitting 
needle heated to a dull-red heat, and if this 
fails to control the bleeding a delicate harelip 
pin should be passed through the skin under 
the bite and a twisted suture should be thrown 
around this ; the wound should then be washed 
and dressed as previously described. 

In applying leeches in or near mucous 
cavities, care should be taken to see that they 
do not escape into the cavities and pass out of 
reach. Leeches should not be employed di- 
rectly over inflamed tissue, but should be ap- 
plied to the parts surrounding it ; they should 
not be allowed to take hold directly over a 
superficial artery, vein, or nerve, and should 
never be applied to a part where there is delicate skin and 
a large amount of loose cellular tissue, as in the eyelid or 
scrotum, as unsightly ecchymoses will result, which will per- 
sist for some time. Leeches should not be used a second time. 




Mechanical 
leech. 



162 



MINOR SURGERY 



Mechanical Leech. 

The mechanical leech is an apparatus which has been 
constructed to take the place of the leech ; it consists of a 
scarificator, cup, and exhausting syringe or air-pump. (Fig. 
103.) In using this apparatus, after the scarificator has 
been used the piston of the exhausting instrument should 
be drawn out slowly, which secures a better flow of blood 
than if a sudden vacuum is made. 

The mechanical leech may be employed when the natural 
leech cannot be obtained, but possesses no advantages over 
the latter, and is apt to get out of order if not in constant 



use. 



Venesection. 



Venesection, as its name implies, consists in the division 
of a vein, and it is the ordinary operation by which general 
depletion or bleeding is accomplished. Venesection at the 
bend of the elbow is the operation which is now usually 
resorted to for general bloodletting ; the vein selected is the 
median cephalic, which is further from the line of the 
brachial artery than the median basilic vein. 




Venesection. (Hfath.) 

To perform venesection the surgeon requires a bistoury 
or lancet — the spring lancet was formerly much used, but it 
is not employed at the present time — several bandages, a 
small antiseptic dressing, and a basin to receive the blood. 

The patient's arm should be carefully cleansed, washed 



VENESECTION. 163 

over with a bichloride solution, and a few turns of a roller 
bandage should be placed around the middle of the arm, 
being applied tightly enough to obstruct the venous circula- 
tion and make the veins below become prominent, but not 
to obstruct the arterial circulation. The patient at the 
same time should be instructed to grasp a stick or a roller 
bandage and work his finger upon it. The surgeon should 
next assure himself that there is no abnormal artery beneath 
the skin, and having selected the vein, the median cephalic 
by preference, he then steadies the vein with his thumb and 
passes the point of the bistoury or lancet beneath it and 
cuts quickly outward, making a free skin opening. The 
blood usually escapes freely, and the amount withdrawn is 
regulated by the condition of the pulse and the appearance 
of the patient. For this reason it is better to have the 
patient sitting up or semi-reclining when venesection is 
performed, as the surgeon can judge better as to the con- 
stitutional effects of the loss of blood while the patient is in 
this position. 

When a sufficient quantity of blood has been removed, 
the thumb is placed over the wounded vein and the bandage 
is removed from the arm above. The wound is next washed 
with a bichloride solution, and a compress of antiseptic gauze 
is applied over the wound and held in position by a bandage, 
which should be so applied as to envelop the limb from the 
fingers to the axilla. The dressing need not be disturbed 
for five or six days, at which time the wound is usually 
found to be healed. 

TTounds of the brachial artery have occurred in opening 
the vein at the bend of the elbow, but if care is taken this 
accident should not take- place. 

Venesection may be practised on the external jugular 
vein when, from excess of fat or in the case of children, the 
veins at the bend of the elbow cannot be easily found. The 
vein is rendered prominent by placing the thumb or a pad 
over the vein at the outer edge of the sterno-cleido-mastoid 
muscle just above the clavicle. The vein is next opened 
over this muscle by an incision parallel to its fibres. After 
a sufficient quantity of blood has escaped, the wound is 



164 MINOR SURGERY. 

washed with an antiseptic solution and closed by a compress 
of antiseptic gauze held in position by a bandage carried 
around the neck. 

Bleeding from this vein has been advocated in cases of 
apoplexy and cerebral inflammation, but it is questionable 
whether any advantage is gained by opening the external 
jugular vein over the vein at the bend of the elbow. 

The internal saphena vein is also sometimes selected for 
venesection, and here care should be taken not to wound the 
accompanying nerve which lies directly behind the vein. 

Arteriotomy. 

This operation is now scarcely ever performed, but if 
done the vessel generally selected is the anterior branch of 
the temporal artery. The position of the vessel is fixed by 
the finger and thumb, and it is opened by a transverse in- 
cision with a bistoury. After a sufficient quantity of blood 
has escaped the wound is inspected, and if the vessel is not 
completely divided, its division is completed ; the wound 
should be washed out with an antiseptic solution and a 
gauze compress should next be applied and held in position 
by a firmly applied bandage. 

Transfusion op Blood. 

This operation may be employed to introduce a certain 
quantity of blood into the circulation of a patient who has 
suffered from profuse hemorrhage. There are two methods 
by which transfusion may be effected : the direct, by which 
the blood is conveyed directly and without exposure to the 
air from the vessel of one person to that of another, and 
the indirect, in which the blood is first drawn from one 
person and is then injected into the vein of another, being 
first deprived of its fibrin before being injected. 



TRANSFUSION OF BLOOD 



165 



Direct Transfusion of Blood. 

This is best accomplished by using Aveling's apparatus, 
which consists of a rubber tube, about eighteen inches in 
length, with a small bulb in the centre, having metallic 
extremities provided with stop-cocks, and two bevel-pointed 
metallic canula? to be used to connect the tube with the 
bloodvessels. In performing the operation of direct trans- 
fusion the bulb and tube are first placed in a shallow basin 
containing warm normal saline solution (0.7 per cent.), and 
the bulb and tube are filled with this solution to displace 
any air which they contain. The person supplying the 

Fig. 105. 




Apparatus for the direct transfusion of blood. 



blood places his arm near the arm of the patient, and the 
operator exposes a prominent vein on the patient's arm at 
the bend of the elbow and opens it, and inserts into it one 
of the canula? filled with saline solution, with the point 
directed toward the body, and at the same time an assistant 
should introduce the other canula into a vein at the bend 
of the elbow of the party who supplies the blood. 

The canula? are held in position by assistants, and the 

8* 



166 MINOR SURGERY, 

tube is quickly connected with them, the stop-cocks being 
closed before it is taken out of the saline solution, to pre- 
vent the entrance of air; then upon opening the stop-cocks 
a direct communication is established between the circula- 
tion of the patient and the donor. (Fig. 105.) The in- 
troduction of the contents of the bulb into the vein of the 
patient is effected by the operator slowly compressing the 
bulb with one hand, while he keeps the tube closed on the 
side of the donor with the finger and thumb of the other 
hand. By relaxing the pressure on the tube on the donor's 
side of the bulb and closing it on the patient's side, blood 
will flow from the donor's vein into the bulb as it slowly 
expands, and when filled the communication with the 
patient's circulation is again made, and the manipulation is 
repeated until a sufficient quantity of blood has been intro- 
duced as indicated by the condition of the patient's pulse. 
The quantity of blood or saline solution introduced can be 
calculated by remembering that at each emptying of the 
bulb two drachms of fluid are introduced into the circula- 
tion. When a sufficient quantity has been introduced the 
canulse are removed and the wounds are dressed as ordinary 
venesection wounds. 

Indirect Transfusion of Blood. 

Indirect transfusion of blood is accomplished by with- 
drawing from a vein of the donor by venesection about ten 
ounces of blood, which is received in a clean glass or porce- 
lain vessel, which is placed in water at a temperature of 
110°. The blood thus kept warm is next defibrinated by 
whipping it with a bundle of broom straws or a wire brush, 
and after being filtered through a fine linen cloth or wire 
strainer, it is injected by means of an ordinary syringe 
attached to a canula which has previously been inserted into 
a vein of the patient ; care should be taken that no air is 
introduced with the blood. When a sufficient quantity of 
blood has been introduced, the canula is removed and the 
wound is dressed in the usual manner. The success of this 
operation largely depends upon the expedition with which 



TRANSFUSION OF BLOOD. 



167 



it is performed ; to prevent the coagulation of the blood not 
more than two minutes should be allowed to intervene be- 
tween the reception of the blood in the syringe and its in- 
troduction into the patient's vein. 

Various forms of apparatus have been devised for the 
operation of indirect transfusion of blood, and of these one 



Fig. 106. 




\J 



Apparatus for the indirect transfusion of blood. 

of the best is that devised by Dr. J. G. Allen and modified 
by the late Dr. C. T. Hunter. (Fig. 106.) 

A rteria I Transfusion . 

This procedure, which consists in injecting defibrinated 
venous blood into an artery, is occasionally practised. An 
artery, usually the radial at the wrist or the posterior tibial 
behind the inner malleolus, is exposed and secured by a 
ligature ; it is then opened on the distal side of the ligature 
and the point of a canula or the nozzle of a syringe is in- 
troduced, directed toward the distal extremity of the limb, 
and blood, which has been previously defibrinated, is slowly 
injected. When a sufficient quantity has been introduced 
the canula is removed, and the division of the artery is 
completed and its extremities are secured by ligatures, and 
the wound is closed and dressed. 



168 MINOR SURGERY. 



A uto-transfusion. 



This procedure is recommended in cases of excessive 
hemorrhage to support a moribund patient until other means 
of resuscitation can be adopted. It consists in the applica- 
tion of rubber bandages or of muslin bandages to the ex- 
tremities for the purpose of forcing the blood toward the 
vascular and nervous centres. 



Intra-venous Injection of Saline Solution. 

It has been proved by experiments and by clinical expe- 
rience that human blood is not more efficacious in supplying 
volume to and restoring a rapidly failing circulation than 
normal salt solution, and as the latter can be obtained with 
much more ease than blood, its use has largely superseded 
the latter. The saline solution which is found most satis- 
factory to employ for this purpose is known as normal saline 
solution (0.7 per cent.). 

The solution should be prepared with water which has 
been boiled to sterilize it, and should be of a temperature of 
about 100° when used. 

A vein of the patient, at the elbow, should be exposed 
and should have placed under it, about one-half inch apart, 
two catgut ligatures ; the distal ligature is then tied and an 
opening is made into the vein between the ligatures; a canula 
is next inserted into the opening into the vein, and is secured 
in position by tying the proximal ligature. The canula is 
first filled with the saline solution, and is then connected 
with a funnel by means of a rubber tube (Fig. ] 07), which 
is filled with saline solution to displace the air, and upon 
raising the funnel above the part the solution enters the 
vein ; care should be taken to see that the funnel is kept 
well supplied with solution until a sufficient quantity has 
been introduced. The quantity introduced is regulated by 
the condition of the patient's pulse. 

Saline solution may also be introduced by means of a 
syringe when the apparatus described cannot be obtained. 



INJECTION OF SALINE SOLUTION. 169 

Fig. 107. 




Funnel and tube for intra-venous injection. 
INTRA-VENOUS INJECTION OF MlLK. 

The intra-venous injection of cow's or goat's milk has 
also been employed as a substitute for transfusion of blood 
in patients who have suffered from excessive hemorrhage or 
from diseases which greatly deteriorate the quality of the 
blood, such as pernicious anaemia, typhoid fever, and in 
carbolic acid poisoning. In making one of these injections 
the milk should be fresh and should be warmed and strained 
through a fine wire or linen strainer, and it should be in- 
troduced by means of a canula inserted into a vein and 
secured in position by a ligature ; to this canula is attached 
the rubber tubing and funnel, such as is employed in the 
intra-venous injection of saline solutions. The funnel and 
tube are next filled with milk prepared as above described, 
and it is made to enter the vein of the patient by turning 
the stop-cock and raising the funnel above the patient's 
body. This injection has been employed in the class of 
cases mentioned above with apparently beneficial results. 



170 minor surgery. 

Artificial Kespiratton. 

This procedure is resorted to in cases of threatened death 
from apnoea consequent upon drowning, profound anes- 
thetization or the inhalation of irrespirable gases, or any 
cause which checks or interferes with the function of breath- 
ing. Before resorting to artificial respiration care should 
be taken to see that nothing is present in the mouth or air- 
passages which will obstruct the entrance of air into the 
lungs, such as mucus, foreign bodies or liquids, and also 
that all tight clothing should be removed from the chest 
which will interfere with the free expansion of the chest 
walls. 

When artificial respiration is resorted to the operator 
should persevere with it for some time, even when no 
apparent spontaneous respiratory movements are excited ; 
for resuscitation has been accomplished in seemingly hope- 
less cases by patient perseverance with the manipulations. 

When the first natural respiratory movement is detected 
the operator should not cease making artificial respiration, 
but should continue these movements in such a way as to 
coincide with the spontaneous inspiratory and expiratory 
movements until the breathing has assumed its regular 
character. 

The temperature of the body should also be restored by 
frictions to the surface of the body by the hands or by rough 
towels and hot-water bottles, and warm coverings should be 
applied for the same object. 

Mouth-to- Mouth Inflation. 

This method of artificial respiration has been resorted to 
in cases of great emergency, especially in very young chil- 
dren. The operator draws the tongue forward, closes the 
nostrils, and applies his mouth directly to the mouth of the 
patient, and by a deep expiratory effort endeavors to. force 
air into the chest ; when this is accomplished the air can be 
expelled from the lungs by pressure upon the walls of the 
chest, and the procedure should be repeated about sixteen 



ARTIFICIAL RESPIRATION. 171 

times in a minute. The same object may be accomplished 
by passing a flexible catheter into the trachea through the 
mouth, or by passing an intubation-tube, to the upper part 
of which a rubber tube is attached, into the larynx ; this 
can be passed with the fingers without difficulty, and the 
lungs can then be inflated by the operator blowing into the 
catheter or tube, or by attaching to it a pair of bellows. 

Inflation of the lungs through the nostrils has been em- 
ployed by Dr. Richardson, of London, who has devised a 
pocket- bellows for this object. The apparatus consists of 
two elastic bulbs, to which two rubber tubes are attached, 
which terminate in a single tube. In using this bellows the 
terminal tube is introduced into one nostril, the other nostril 

Fig. 108. 




Richardson's bellows for artificial respiration. 

and mouth being closed ; air is forced into the lungs by com- 
pressing one bulb, and withdrawn by compressing the other 
bulb. 

This bellows may also be attached to a catheter or in- 
tubation-tube passed into the larynx, which would prevent 
the possibility of air escaping into the oesophagus, which is 
a complication which is liable to occur in mouth-to-mouth 
inflation or inflation through the nose. 

Direct Method of Artificial Respiration (Howard's). 

This method of artificial respiration is at the present time 
considered the most efficacious, and is the one adopted by 
the United States Life Saving Service, and although the 



172 



MINOR SURGERY. 



rules given are for the resuscitation of cases of apparent 
drowning, the same procedures may be adopted in cases of 
apnoea arising from other causes. 

The rules laid down by Dr. Howard are as follows : 

Rule I. — " To expel water from the stomach and lungs, 
strip the patient to the waist, and if the jaws are clenched 
separate them and keep them apart by placing between the 
teeth a cork or a small piece of wood. Place the patient 
face downward, the pit of the stomach being raised above 
the level of the mouth by a large roll of clothing placed 
beneath it. (Fig. 109.) Throw your weight forcibly two 
or three times upon the patient's back over the roll of 

Fig. 109. 




First manipulation in Howard's method. 



clothing so as to press all fluids in the stomach out of the 
mouth." 

The first rule applies only to cases of drowning, and in 
using Howard's method in apncea from other causes it is to 
be omitted. 

Ride II — " To perform artificial respiration, quickly 
turn the patient upon his back, placing the roll of clothing 
beneath it so as to make the breast-bone the highest point 



ARTIFICIAL RESPIRATION. 



173 



of the body. Kneel beside or astride of the patient's hips. 
Grasp the front part of the chest on either side of the pit 
of the stomach, resting the fingers along the spaces between 
the short ribs. Brace your elbows against your sides, and 
steadily grasping and pressing forward and upward throw 
your whole weight upon the chest, gradually increasing the 
pressure while you count one — two — three. Then suddenly 
let go with a final push which springs you back to your 
first position. (Fig. 110.) Rest erect upon your knees 
while you count one — two ; then make pressure again as 
before, repeating the entire motions at first about four or 
five times a minute, gradually increasing to about ten or 

Fig. 110. 




twelve times. Use the same regularity as in blowing bel- 
lows and as seen in the natural breathing which you are 
imitating. If another person is present let him with one 
hand, by means of a dry piece of linen, hold the tip of the 
tongue out of one corner of the mouth, and with the other 
hand grasp both wrists and pin them to the ground above 
the patient's head." 

This method may be employed in cases of still-birth or in 
young children, the operator holding the chest of the child 
in his left hand and compressing it with the right hand. 



174 



MINOR SURGERY. 



Sylvester 's Method of Artificial Respiration. 

In employing this method of artificial respiration the 
patient should be placed on his back upon a firm flat sur- 
face ; a cushion of clothing is placed under the shoulders, 



Fig. 111. 




Sylvester's method — Inspiration. (Esmarch.) 



and the head should be dropped lower than the body by 
tilting the surface on which he is laid. The mouth being 
cleared of mucus or foreign substances, the tongue is drawn 
forward and secured to the chin by a piece of tape tied 
around it and the lower jaw, or may be pulled out of the 
mouth and held by an assistant. The operator, standing at 
the patient's head, grasps the arms at the elbows and carries 
them first outward and then upward until the hands are 
brought together above the head ; they should be kept in 
this position for two seconds, after which time they are 
brought slowly back to the sides of the thorax and pressed 
against it for two seconds. These movements are repeated 



ARTIFICIAL RESPIRATION. 175 

fifteen times in a minute until the breathing is restored, or 
until it is evident that the case is a hopeless one. 

Fig. 112. 




Sylvester's method — Expiration. (Esmarch.) 

Marshall RalVs Beady Method of Artificial Respiration. 

In this method the mouth should first be freed from 
mucus or foreign bodies, and the patient is turned upon his 
face with one wrist under his forehead, and a roll of clothing 
is placed beneath his chest. By turning the body briskly 
on the side and a little beyond, and then on the face, alter- 
nately, respiration is imitated. As the body is brought in 
the prone position, compression is to be made upon the 
posterior aspect of the chest. These manipulations should 
be made fifteen times in a minute. 

In using any of these methods of artificial respiration 
the operator should persevere with them for an hour at least 
before abandoning the case as a hopeless one. 

In cases where the apncea is due to the presence of a 
foreign body in the larynx or trachea, it is evident that no 
efforts at respiration can be successful until the air-passages 



176 MINOR SURGERY. 

are freed from the occluding body, and in such cases tra- 
cheotomy should be performed before artificial respiration is 
attempted ; the tracheal wound should be held open by 
retractors, which in a case of emergency can be made from 
bent hairpins, or by a tracheotomy-tube if one be at hand. 

Forced Respiration. 

This is that method of artificial respiration by which air is 
forcibly passed into the lungs. This procedure is strongly 
advocated by Dr. George E. Fell, who has devised an apparatus 
by which it may be satisfactorily accomplished. Prof. H. C. 
Wood has also made use of forced respiration in the resus- 
citation of animals with an apparatus somewhat similar to 
that devised by Dr. Fell with good results, but has never 
applied it practically in the case of the human subject. 
Wood's apparatus consists of a pair of bellows, a few feet 
of rubber tubing and a face mask of rubber, and one or two 
intubation-tubes ; the mask or intubation-tube is attached 
to one end of the rubber tube and the bellows to the other 
end of the tube. The mask is applied over the mouth, or 
if this is not used the intubation-tube is introduced into the 
larynx, and air is forced into the lungs by working the 
bellows. He also advises that in the tubing a double metal 
tube be introduced, with openings so placed that their size can 
be so regulated by turning the outer tube, that the operator 
can allow any excess of air thrown by the bellows to 
escape. 

The apparatus of Fell, which he has used in a number of 
cases with good results, consists of a tracheotomy-tube, a 
tube connected with the air-control valve, which is attached 
to an air-warming apparatus, which in turn is connected 
with a bellows by another tube. In this apparatus air is 
forced into the lungs and allowed to escape when the lungs 
have been expanded by the elasticity of the lung tissue and 
the chest walls. 

Forced respiration will prove of value in cases of narcotic 
poisoning and other accidents in which death is produced 
by paralysis of the respiratory centres. Dr. Fell has re- 



ASPIRATION. 



177 



ported a number of cases of narcotic poisoning in which he 
has used his apparatus with the most satisfactory results. 



Aspiration. 



This procedure is adopted to remove fluid from a closed 
cavity without the admission of air, and the instrument 
which is employed to accomplish this object is known as 
an aspirator. The two forms of aspirator most generally 
employed are those of Dieulafoy and Potain. (Fig. 113.) 



Fig. 113. 




Aspirator 



Potain's aspirator consists of a glass bottle, into the 
stopper of which is introduced a metallic tube, which is con- 
nected with two rubber tubes, one of which is connected with 
an exhausting pump, and the other with a delicate canula 
carrying a fine trocar ; the apparatus is provided with stop- 
cocks to prevent the admission of air. In using this aspi- 
rator the bottle is exhausted of air by using the air-pump ; 
the canula enclosing the trocar is next pushed through the 
tissues into the cavity containing the fluid to be removed ; 
the trocar is next removed, and upon opening the stop-cock 



178 MINOR SURGERY. 

the fluid is forced out of the cavity by atmospheric pressure 
and passes into the bottle or receiver. If the fluid contains 
masses of lymph or clots which block the canula, interrupt- 
ing the flow of fluid, a stylet is passed through the canula 
to free it of the obstruction. 

To diminish the pain produced in introducing the trocar 
and canula, the skin at the point to be punctured may be 
rendered less sensitive by holding in contact with it for a 
few minutes a piece of ice wrapped in a towel, or a towel 
containing broken ice and salt. Care should also be taken 
to see that the trocar and canula are perfectly clean ; to 
accomplish this it should be carefully washed and placed in 
boiling water or a 5 per cent, carbolic solution before being 
used. 

In introducing the trocar and canula the operator should 
be careful to avoid injuring any important veins, arteries, 
or nerves. 

After removing the canula the small puncture should be 
dressed with a compress of antiseptic or iodoform gauze 
held in place by a bandage or adhesive straps. 

The aspirator is frequently employed in cases of hydro- 
thorax, empyema and ascites, to evacuate the contents 
of cold abscesses in diseases of the hip and spine, and to 
remove the contents of a distended bladder until a more 
radical operation can be performed. It is also .a valuable 
instrument for diagnostic purposes, being frequently used 
to ascertain the character of the contents of deep-seated 
tumors containing fluid. 

The Stomach-tube. 



This consists of a tube about twenty- eight inches in length 
and three-eighths of an inch in diameter, which is intro- 
duced while the patient is in the sitting posture, the head 
being thrown backward so as to bring the mouth and gullet 
as nearly as possible in the same line. The tube being 
warmed and oiled, the surgeon standing in front of the 
patient passes it directly back to the pharynx, at the same 



STOMACH-TUBE. 



179 



time introducing the index finger of the left hand to guide 
its point over the epiglottis ; it is then passed gently down- 
ward into the stomach. If any obstruction is met with in its 
passage it should be withdrawn a little way and then pushed 
gently downward ; all manipulations should be made with- 
out much force to prevent perforation of the wall of the 
oesophagus. 

The introduction of the stomach-tube may be required 
for the evacuation of poisons from the stomach, or to wash 
out the cavity of this viscus, and it may also be used to 
introduce liquid nourishment into the stomachs of patients 
who are unable or unwilling to swallow food. In the 
recently introduced method of treating disorders of the 
stomach and intestines by washing them out, lavage, the 
introduction of a stomach-tube is required ; the tube here 
employed is from twenty-four to thirty inches in length 
(Fig. 114), and the fluid is introduced by means of a funnel 

Fig. 114. 




attached to its free extremity, or it may be attached to a 
stomach-pump. In introducing liquid nourishment a syringe 
or funnel is fitted to the exposed end of the tube which has 
been passed into the stomach ; the syringe or funnel having 
been filled with milk or beef-tea or broth, the contents are 
injected gently or allowed to run into the stomach. 

In cases of poisoning, where it is desirable to withdraw 
the contents of the stomach and to wash out the organ, a 
stomach-tube and syringe may be employed ; several syringe- 
fuls of warm water are first thrown into the stomach and 
then withdrawn by suction, but in such cases the use of the 
stomach-pump will be found more satisfactory. 



80 



MINOR SURGERY. 



The Stomach-pump. 

This consists of a brass syringe, the nozzle of which is 
connected with two tubes, one at the end, the other at the 
side. The passage through the nozzle is regulated by a 
valve controlled by a lever. The nozzle of the pump is 
attached to the stomach-tube, and the end of the lateral tube 
is placed in a pan of warm water. By raising the piston 
and opening the valve, water may be drawn from the basin, 
and by closing the valve and depressing the piston it is 
passed through the stomach-tube into the stomach ; when a 
sufficient quantity has been injected in this manner, by 
reversing the action of the valve the fluid is drawn out of 
the stomach and discharged through the lateral tube into a 
basin. This manipulation is continued until the water 
returns clear and the stomach has been completely washed 
out. A less complicated instrument will often serve as well 
as that just described (Fig. 115). 



Fig. 115. 




Stomach-pump. 

(Esophageal Bougie. — This instrument — which may be 
passed through the oesophagus into the stomach for the 
purposes of diagnosis, or for the purpose of dilating stric- 
tures of the oesophagus — is passed in exactly the same 



Vaccination. 181 

manner as the stomach-tube, and, as in the case of the latter 
instrument, it should be introduced without the use of much 
force, as perforations of the oesophagus have followed the 
forcible introduction of such bougies. 



Vaccination. 

This is a minor surgical procedure which every physician 
is called upon to perform. The surface may be prepared 
for the reception of the lymph by abrading the surface of 
the skin at one or two points with a dull lancet, or by 
making several superficial incisions with a knife, or by 
scratching the surface of the skin with the ivory-point 
charged with lymph, in lines with crossing lines, cross- 
scratch, until a little serum exudes. It is not advisable to 
draw blood, which washes away the lymph, and for this 
reason I prefer the abraded surface made by the dull knife 
or the ivory-point. 

The lymph used may be the humanized or the bovine. 
The humanized lymph may be the viscid fluid taken from 
the vaccine vesicle on the eighth or ninth day, or the dried 
scab which separates when the wound is about healed ; if 
the latter is used, a small portion of it is rubbed up with 
water until it forms a mixture of creamy consistence : this is 
rubbed into the abraded surface or the punctures. In using 
humanized lymph care should be taken to see that it is 
procured from a healthy subject. 

Bovine lymph or virus, which is now most generally 
employed, is taken from the vaccine vesicles upon the udders 
and teats of heifers ; ivory-points or quills are dipped into 
this lymph and allowed to dry, and in using them they are 
dipped in water for a moment, to moisten the lymph, before 
being applied to the abraded surface. The ivory-point is 
one of the most convenient means of vaccinating, as the 
surface may be abraded with it before the lymph is applied. 

It has recently been advised that antiseptic precautions 
be exercised in performing vaccination, and although all of 
the details cannot be carried out, I have found that the 

9 



182 MINOR SURGERY.] 

exercise of care as regards cleanliness of the surface has 
been followed by much fewer inflammatory complications in 
vaccination wounds. In an institution in which I vaccinate 
yearly a large number of cases, since I have adopted the 
following precautions I have had fewer bad arms. 

The surface to be abraded, usually the left arm below the 
deltoid, is first washed with soap and water, and then with a 
1 : 2000 bichloride solution. Two points of this surface, an 
inch apart, are then abraded by using a knife which has 
been washed or dipped in boiling water, or by using the 
ivory-point which has been dipped in water which has been 
boiled and cooled down. When the surface has been pre- 
pared in the manner described, the moistened virus is rubbed 
upon it and allowed to dry. Vaccination upon the leg, 
which is practised by some physicians to prevent the scar 
from showing, I think is not to be recommended, and I never 
practise it in this situation, as it is more difficult to keep this 
part at rest, and I have seen some very severe cases of cel- 
lulitis and phlebitis follow leg vaccination. 

Hypodermic Injections. 

The syringe used to make hypodermic injections is pro- 
vided with a perforated needle, which is passed into the 
cellular tissue. (Fig. 116.) Care should be taken to see 
that the instrument and needle are perfectly clean before 
being used ; if a metallic syringe is employed it should 
be rendered aseptic by soaking it for a few minutes in 
boiling water, or in a five per cent, carbolic solution. 
Hypodermic injections are generally made into parts in 
which the cellular tissue is abundant, and great care should 
be observed to avoid introducing the needle into a large vein 
or artery, as by neglect of this precaution serious symptoms 
have resulted, from the drug being thrown rapidly into the 
circulation instead of being slowly absorbed from the sub- 
cutaneous cellular tissue; the injury of superficial nerves 
should also be avoided. Care should also be taken to see 
that the solutions employed are sterilized if possible, and 
freshly made solutions should be preferred. 



HYPODERMIC INJECTIONS, 



183 



An unclean syringe or a solution which has not been 
sterilized may give rise to a troublesome abscess at the site 
of the injection. 

Fig. 116. 




oGS3= 



Hypodermic syringe and needles. 

To avoid using solutions for hypodermic use which un- 
dergo change from being kept, it will be found convenient 
to use the compressed pellets which are prepared by the 
manufacturing chemists, the alkaloids being compressed with 
a little sulphate of sodium, which increases their solubility, 
the solution being prepared with boiled water just before 
being used. 

The portions of the body usually selected for hypodermic 
injection are the outer surface of the thighs or arms and 

Fig. 117. 




Method of giving a hypodermic injection. 

the anterior surface of the forearm. In making a hypo- 
dermic injection the syringe is charged and the needle is 
fastened to the nozzle of the syringe; the skin is next 
pinched up and the needle is quickly thrust through this 



184 



MINOR SURGERY, 



into the cellular tissue ; the syringe is then emptied by 
pressing down the piston, and when the cylinder is empty 
the needle is withdrawn ; the small puncture in the skin 
resulting seldom bleeds and usually heals without difficulty. 
(Fig. 117.) In patients who have suffered from profuse 
hemorrhage, where transfusion of blood is not considered 
advisable, large injections of normal salt solution may be 
introduced into the cellular tissue by means of hypodermic 
injections, or the needle may be introduced into the cellular 
tissue and connected by a piece of rubber tubing, with an 
irrigator containing normal salt solution held above the 
part, and the solution gradually finds its way into the sub- 
cutaneous cellular tissue. A large quantity of fluid may 
be introduced in this way. 

Exploring Needle. 

This consists of a fine-grooved needle fitted into a handle 
(Fig. 118), which is introduced into tumors or swellings to 

Fig. 118. 



Exploring needle. 

ascertain the nature of their contents, and its use is often 
of service for purposes of diagnosis. The exploring trocar 
(Fig. 119) is employed for the same purpose, or the needle 

Fig. 119. 




Exploring trocar. 

of the hypodermic syringe or a fine needle attached to an 
aspirator may be used for a like purpose. When either the 
exploring needle or trocar is employed care should be taken 



SKIN-GRAFTING. 185 

to see that it is rendered perfectly aseptic before being used; 
otherwise its employment is not without danger, for I have 
seen the introduction of an exploring needle into an effusion 
in a joint for diagnostic purposes followed by suppuration 
and destruction of the joint, which subsequently necessitated 
its excision. 

Skin-grafting. 

This is a minor surgical procedure which may be em- 
ployed to hasten cicatrization where large granulating sur- 
faces are exposed, such as result from extensive operations 
and from burns. 

The operation consists in applying shavings of the epi- 
dermis or of the epidermis and cutis together, to the granu- 
lating surface and holding them in contact with it for a few 
days ; the grafts often seem to disappear, but at the end of 
a few days, if the part is closely inspected, bluish-white 
points will be seen to occupy the positions at which the 
grafts were applied, which become converted into isolated 
cicatrices from which the healing process rapidly extends. 
To have a successful result following the use of skin-grafts 
the surface of the ulcer should be healthy, and the grafts 
should be applied at a number of points. 

Fig. 120. 




Scissors for skin-grafting. 

The skin is removed by scissors made for this purpose 
(Fig. 120), or by raising the epideimis with a needle or with 
forceps and cutting out a small portion of it with a sharp 



186 MINOR SURGERY. 

scalpel. The graft is next applied to the granulating sur- 
face with its raw surface in contact with the granulations ; 
after a sufficient number of grafts have been applied, a piece 
of sterilized protective is laid over them and held in place by 
means of a few strips of isinglass plaster. An ordinary 
antiseptic gauze dressing is next applied, and the dressing is 
not disturbed for a week or ten days, at which time, if the 
grafts have taken, isolated cicatrices at the points where the 
grafts were applied will be found to exist. 

Electrolysis. 

Electrolysis, or the chemical decomposition induced by 
electricity, is employed in surgery to destroy morbid prod- 
ucts, tumors, or exudations. For this procedure a galvanic 
or continuous-current battery is required, which is provided 
with electrodes and needles of suitable shapes. In applying 
electrolysis to a tumor, for instance, the needle connected 
with one of the poles of the battery is inserted into the tumor 
and the other rheophore is applied to the surface of the body, 
or two fine needles, carefully insulated nearly to their 
extremities, are connected with both poles of the battery by 
conducting cords ; these are introduced into the tumor and 
a weak current is allowed to pass, and its strength is grad- 
ually increased as the operation advances ; the current is 
passed for fifteen or twenty minutes, and the procedure is 
repeated at intervals of several days, until some decided 
change occurs in the tumor. 

Electrolysis has been applied with success in the treatment 
of aneurism inaccessible to other operative procedures, in 
malignant growths, in nsevi, goitres, cysts, hydatids, and is 
at the present time the most satisfactory method of removing 
superfluous hairs from those portions of the body in which 
their presence causes disfigurement. 

Galvano-cautery. 

Galvano- cautery batteries are constructed with plates of 
large size, placed closely together, so that the internal 



FARADIZATION 



187 



resistance is reduced and a current is quickly obtained which 
will keep a metallic electrode at a white heat. The advan- 
tage in the use of this form of cautery is that the electrode 
can be introduced into the various cavities of the body while 
cold and quickly heated to the desired temperature. The 
electrodes are made of various shapes and sizes, according 
to the object desired (Fig. 121). Galvano-cautery is applied 




Electrodes for galvaco-cauteiy. 

for the same purposes as the actual cautery, but, as pre- 
viously stated, its use is more convenient in the various 
cavities of the body, its action can be more easily localized, 
and by its use hemorrhage is avoided. It is frequently 
employed to destroy morbid growths in the nasal passages, 
the throat, vagina, or uterus, and also may be employed in 
the treatment of superficial external growths ; in using it for 
the removal of growths from the mucous membrane, its 
application may be rendered practically painless by pre- 
viously thoroughly cocainizing the parts. 



Faradization. 



The application of electricity in this form is often em- 
ployed in surgical affections ; in cases of wasting of the 
muscles following fractures or sprains, in some forms of club- 
foot, and in lateral curvature of the spine the judicious use 
of the faradic current will often be found to be followed by 
the most satisfactory results. The current is applied in such 
a manner as to bring about contraction of the affected or 
wasted muscles, and thus improve their nutrition. 



188 MINOR SURGERY. 



Massage. 

Massage consists in a variety of manipulations, such as 
pinching up the integuments and muscles, and rolling them 
between the thumb and fingers, in stroking or rubbing the 
surface with the palm of the hand from the periphery 
toward the centre, to empty the distended veins and lym- 
phatics ; rubbing the parts circularly with the extremities 
of the fingers and thumb or the palm of the hand, or 
kneading of the parts is another method of practising 
massage. Massage may also be practised by tapping the 
surface of the affected part with more or less force with the 
tips of the fingers held in a row, or with the ulnar border 
of the hand or with the palm of the hand. Before apply- 
ing massage to an affected part, if there be a heavy growth 
of hair, it should be carefully shaved off; otherwise the 
manipulation may give the patient pain, and irritation of the 
hair follicles resulting in abscesses will be apt to occur. 
The part should also be rubbed over with olive oil, vaseline, 
or cocoa-butter before and during the manipulations. 

Massage is often employed with advantage in the treat- 
ment of sprains and strains in their subacute and chronic 
states, and it will be found of great service in the later 
treatment of fractures involving the joints or their vicinity, 
in regaining the motion of the parts as well as in improving 
the nutrition of the muscles which have become wasted 
from disuse. 

Passive Motion. 

This manipulation consists in alternately flexing and ex- 
tending or rotating the limb to imitate the normal joint move- 
ments. The motions should be carefully practised, and in cases 
of fracture they should not be undertaken until there is quite 
firm union at the seat of fracture, or if for any reason passive 
motion is made use of before this time the fragments should 
be firmly supported while it is being employed. Other 
forms of massage, such as stroking and kneading, may be 
employed in conjunction with passive motion in the treat- 



THE CLINICAL THERMOMETER. 189 

ment of the troublesome stiffness of the joints resulting from 
fractures, dislocations, and sprains ; passive motion applied 
in this manner will often restore the function of a stiff joint 
more satisfactorily and with less pain to the patient than 
the forcible manipulations of the joint which are practised 
under an anaesthetic. 

The Clinical Thermometer. 

For clinical observations two thermometer scales are in 
general use, the Centigrade and Fahrenheit ; the latter is 
the one commonly employed in America and England. 
This scale has a limited range above and below the normal 
bodily temperature, which is 98|- Fahrenheit or 36° Centi- 
grade. Thermometers are now made with a convex surface, 

Fig. 122. 



5) 



9 5 100 5 110 



Clinical thermometer. 

which serves to magnify the column of mercury, and thus 
enables the observer without difficulty to note the position of 
the index. (Fig. 122.) 

The temperature of the body may be taken in the mouth, 
axilla, vagina, or rectum ; the two former positions are those 
generally employed. "When taken in the axilla care should 
be exercised to see that no clothing is interposed between 
the skin and the instrument, and when the mouth is used 
for thermometric observations the patient should be in- 
structed to keep his lips tightly closed and breathe through 

Fig. 123. 




Surface thermometer. 



his nose. The thermometei should be kept in place for 
from three to five minutes. 

Surface thermometers are sometimes employed, the in- 



9* 



190 MINOR SURGERY. 

struments for this purpose having bulbs of a discoid shape, 
or are drawn out in the form of a spiral or coil. (Fig. 123.) 
In using this form of thermometer to determine the amount 
of variation of the surface temperature, the temperature of 
corresponding parts of the body on the opposite side and 
the general temperature of the body should be taken at the 
same time. 

The Rectal Tube. 

The introduction of the rectal tube is best accomplished 
by placing the patient upon his left side, and the surgeon 
should introduce his index finger well oiled into the rectum 
and guide the tube upon this through the anus, and by 
gentle pressure it is gradually passed into the rectum ; if a 
stricture exists in the rectum within reach of the finger, the 
latter should be used to guide the tube through the opening 
in this ; if the tube becomes caught in a transverse fold of 
the mucous membrane, and becomes doubled upon itself, it 
should be withdrawn and a fresh attempt should be made to 
pass it ; in passing a rectal tube all manipulations should be 
made with extreme gentleness, as it has been shown that its 
passage is not without danger, perforations of the intestine 
having followed its use in some cases. In cases of stricture 
of the rectum high up, the operator has to depend upon the 
sense of resistance experienced in passing the tube, and in 
such cases the manipulations should be most carefully made. 
When the rectal tube is employed to introduce fluids into the 
large intestine, the fluids may be introduced by means of a 
syringe, or by pouring them into a funnel attached to the free 
end of the tube, or by attaching the tube to a fountain 
syringe, thus allowing the liquid to pass slowly into the 
intestine. 

The rectal tube is often employed with good results in 
relieving the intestine of excessive flatus, and in introducing 
water or oil into the intestine in cases of intestinal obstruc- 
tion, and in those cases where the obstruction results from 
intussusception or fecal accumulations its use will often prove 
most satisfactory. 



NUTRITIOUS ENEMATA. 191 



Rectal Bougies. 



These instruments are made of the same material as the 
English flexible catheter, and are of various sizes. They 
should first be oiled, and carefully introduced in the same 
manner as the rectal tube. They are generally employed in 
cases of stricture of the rectum, and they should be used with 
great care to avoid perforating the wall of the rectum. A 
very satisfactory substitute for a rectal bougie is a tallow 
candle, one end of which is melted or rubbed down to a 
conical shape. 

Enemata. 

These may be administered by means of the ordinary 
syringe, or by means of a gravity or fountain syringe ; the 
precautions which should be observed are to introduce the 
nozzle of the syringe gently and in the right direction, as 
perforation of the lower portion of the rectum has taken 
place from the careless and forcible introduction of the 
nozzle of the enema-syringe ; the fluid should also be 
injected slowly, as by so doing there is less resistance and 
less tendency for the patient to pass the fluid before the de- 
sired quantity has been introduced. 

The enema most commonly employed to empty the lower 
bowel is made by adding a tablespoonful of sweet oil and two 
teaspoonfuls of spirits of turpentine to one or two pints of 
warm water in which a little Castile soap has been dissolved ; 
warm water and sweet oil are also frequently used for the 
same purpose. 

Glycerin Enema. — One or two teaspoonfuls of glycerin 
injected into the rectum, or a suppository made of glycerin, 
will often be found an efficient substitute for the larger 
enemata of water. 

Nutritious Enemata. 

When it is found necessary to resort to feeding by the 
rectum, the substances employed should be injected into the 



192 MINOR SURGERY. 

rectum by means of a syringe, and care should be taken to 
see that the quantity is not too large, and that it is of such 
a nature as not to cause any irritation of the walls of the 
rectum, or it will not be retained ; two ounces in the case of 
an adult is generally a sufficient quantity to inject at one 
time. 

Peptonized milk or beef juice, or the yolk of an egg beaten 
up with milk, are often employed, and any unirritating drugs 
may be mixed with the enema and administered at the same 
time. 

Anaesthetics. 

The substances which are employed at the present time 
to produce either local or general anaesthesia are ice, cocaine, 
rhigolene, nitrous oxide, chloroform, and ether. 

Local Anesthesia. 

Gold. 

Local anaesthesia may be produced by the application of 
cold, either by a piece of ice or a mixture of ice and salt 

Fig. 124. 



Application of rhigolene spray. 

held in contact with the part for one or two minutes, or by 
directing a spray of rhigolene upon the surface of the part 
whose~sensibility is to be obtunded. (Fig. 124 ) This form 
of^local anaesthesia is made use of in minor surgical pro- 



LOCAL ANAESTHESIA. 193 

cedures, such as aspiration, the opening of abscesses, and 
the removal of superficial tumors. 

Rapid Respiration. 

Rapidly repeated deep inspirations kept up for a few 
minutes will produce insensibility to pain, but sensibility to 
contact is not obliterated. This form of anaesthesia may 
be made use of in slight operations, such as the opening of 
abscesses. 

Cocaine. 

Local anaesthesia produced by the employment of an 
aqueous solution of the hydrochlorate of cocaine, in strength 
from 2 to 12 per cent., is often made use of in minor sur- 
gical procedures, where the mucous membrane is to be oper- 
ated upon or growths removed from it. Analgesia is pro- 
duced by brushing the surface over with the solution of 
cocaine, or by applying a compress of absorbent cotton 
saturated with the solution to the part for a few minutes ; 
in mucous cavities the latter method of application will be 
found most convenient. In using a solution of cocaine to 
produce anaesthesia in operations upon the eye a 2 or 4 per 
cent, solution is dropped into the eye, and the application is 
repeated until the analgesia is complete. 

In applying cocaine to the urethra a 4 to 10 per cent, 
solution is injected into the urethra, and is allowed to remain 
for two or three minutes ; more than one or two grains should 
not be injected at one time. 

When it is desired to produce local anaesthesia of the 
skin or deeper tissues the application of the solution of 
cocaine to the surface is not satisfactory, and it should in 
such cases be injected hypodermically into the deeper layers 
of the skin and into the cellular tissue of the parts to be 
operated upon ; to avoid mutiple puncture the needle is not 
completely withdrawn from the wound, but its direction is 
changed and the solution is thrown into different portions 
of the tissues. It is well, in situations where it can be 
accomplished, to cut off the circulation from the part to be 



194 MINOR SURGERY. 

operated upon by placing around it a rubber strap or tube, 
which prevents its rapid absorption into the general blood 
current. It is well not to inject more than one grain of 
the drug in this way, for fatal results have followed the 
injection of larger quantities ; this is especially the case in 
using cocaine in the urethra and rectum, and in these 
situations great caution should be exercised in its use. 

Some persons also have an idiosyncrasy for cocaine, and 
children seem more susceptible to its constitutional effects 
than adults. I have seen several cases in children in which 
marked symptoms of cocaine poisoning resulted from the 
application of a 4 per cent, solution to the nasal mucous 
membrane. 

In minor surgical operations, such as amputations of the 
finger, circumcision, opening of abscesses, and removal of 
superficial tumors, cocaine-anaesthesia may be employed with 
advantage, but its utility is most marked in operations upon 
the eye and those upon the mucous membranes of the nose, 
throat, rectum, vagina, and urethra. Applied to the surface 
of an ulcer for a few minutes, which is to be cauterized, it 
will render the operation almost painless to the patient. 

Nitrous Oxide Gas. 

This gas is administered for the purpose of producing 
anaesthesia, and the apparatus best suited for its adminis- 
tration consists of a cylinder of metal in which the gas is 
compressed ; this is attached to a rubber bag which has a 
mouthpiece fastened to it ; this is provided with a double 
valve, which prevents the expired air from passing back 
into the bag. The mouthpiece is adjusted over the mouth, 
and after removing any false teeth, or foreign bodies, from 
the mouth, the patient is instructed to take deep, full 
breaths, and in from one-half to one minute the face becomes 
congested and dusky, and the breathing becomes stertorous, 
indicating that the patient is fully under the influence of 
the gas. The anaesthesia from nitrous oxide cannot be pro- 
longed for more than a few minutes, so that it can only be 



ANAESTHESIA. 195 

employed in operations which take a short time for their 
performance, such as the extraction of teeth, opening of 
abscesses, and reduction of dislocations or fractures. In 
England nitrous oxide is frequently used to produce anaes- 
thesia, and when this result is accomplished the anaesthesia 
is kept up by the administration of ether by the employ- 
ment of a special apparatus devised for this purpose. Nitrous 
oxide gas is most commonly employed in dental surgery to 
produce anaesthesia for the removal of teeth, but is also 
occasionally employed in minor surgical operations ; but 
from the fact that the apparatus for its administration is a 
bulky one, its use is not as convenient as ether or chloro- 
form, and in this country it is not much employed in gen- 
eral surgery. 

Ether. 

Sulphuric ether is one of the most widely employed sub- 
stances in surgery to produce anaesthesia ; it is probably the 
safest of all anaesthetics, and for this reason should be given 
the preference over all others. 

A patient should be prepared for the administration of 
ether by not allowing him to have any solid food for at least 
six hours before its inhalation ; he should be in the recum- 
bent posture, and any garments about the chest or neck 
should be loosened so that the respiratory movements are 
not interfered with. The surgeon should also see that any 
false teeth or foreign bodies which may be present in the 
mouth are removed before the administration of the drug is 
begun. As the vapor of ether often causes irritation of the 
mucus membrane of the lips and nasal passages, it is well to 
anoint these parts with a little vaseline or cold-cream before 
administering the ether. 

It should also be borne in mind that the vapor of ether 
is very inflammable, and that it is heavier than the air, so 
that lights brought near the patient while being etherized 
should be held at a higher level than the ether can or in- 
haler. 

In administering ether a towel folded into a cone or one 
of the various ether inhalers may be employed. The best 



196 



MINOR SURGERY. 



of these is Allis's inhaler (Fig. 125), which consists of a 
metallic framework covered with leather, which carries a 
number of folds of a roller bandage, giving a large surface 
for the rapid evaporation of the drug. 



Fig. 125. 




Allis's ether inhaler. 



If a towel folded into a cone is used, a few layers of stiff 
paper interposed between the outer layers of the towel will 
keep the cone in shape and will prevent the evaporation of 
the ether from its external surface. 

In debilitated patients or those who are weak from the 
loss of blood the administration of half an ounce to an 
ounce of whiskey from fifteen to thirty minutes before the 
anaesthetic is given is often advisable. 

Half an ounce of ether is next poured over the inner 
surface of the towel or inhaler and it is brought near the 
mouth of the patient, and he is requested to take deep 
breaths or to blow the ether away, and as soon as he has 
become accustomed to the irritating qualities of the ether 
vapor, the cone or inhaler is held firmly over the mouth and 
nose, and the vapor is administered in as concentrated a 
form as possible ; if the respiration and circulation are good 
there is no disadvantage in pushing the ether. When the 
conjunctiva is insensible to the touch of the finger, and the 
muscular relaxation is complete and the breathing tends to 



ANAESTHESIA. 197 

become stertorous, the stage of complete amethesia has been 
reached, and the ether should be withdrawn for a time or 
should be given only in such quantities as suffice to keep 
the patient in this condition. 

The first effect from the inhalation of ether is to produce 
acceleration of the pulse and respiration ; the mucous mem- 
brane of the air-passages is irritated and coughing often 
occurs ; there is also in this stage a disposition to muscular 
movements, and it is frequently necessary to restrain the 
patient ; the brain is also excited and the patient is apt to 
cry out. These symptoms call for a continuance of the 
administration of the ether and not for its withdrawal. 
Succeeding this stage, if the ether is pushed, profound 
anaesthesia takes place, as is evidenced by loss of conscious- 
ness, relaxation of the muscular system, moistened skin, 
loss of the special senses, contracted pupils, and slow and 
deep respiration tending to_ become stertorous. 

Under the name of 'first insensibility from ether there 
exists early in the course of the administration of ether a 
primary anaesthesia, which lasts for a minute or so, and 
w T hich may be taken advantage of to perform such minor 
surgical operations as the opening of an abscess or the re- 
duction of a dislocation or the drawing of a tooth. The 
recovery from this condition is usually very prompt, and it 
is not followed by nausea and the after-effects which attend 
the prolonged administration of ether. During the admin- 
istration of ether, particularly in the early stage, the patient 
may stop breathing, the face at the same time becoming 
cyanosed; this condition calls for the withdrawal of the 
ether, and if a deep inspiration does not quickly follow, 
pressure should be made upon the front of the chest, and 
when this is relaxed a deep inspiration usually takes place 
and no further difficulty is experienced. 

If the patient has eaten solid food shortly before the 
etherization, vomiting is apt to occur; when this takes place 
the ether inhaler should be removed and the head should be 
turned to one side, or the patient should be rolled upon his 
side, the mouth being kept open to facilitate the escape of the 
vomited matters. The breathinsr also sometimes becomes 



198 



MINOR SURGERY. 



obstructed by the accumulation of mucus in the fauces ; 
this should be removed by small sponges securely fastened 
to sponge-holders. 

When the anaesthesia is profound it sometimes happens 
that the muscular relaxation is so complete that the tongue 
falls backward and the glottis is closed, the face becomes 
cyanosed and the pulse frequent and irregular, and death is 
threatened from asphyxia ; in this event the head should be 
extended and the lower jaw should be pressed forward by 
the fingers placed beneath the ramus of the submaxillary 
bone. (Fig. 126.) This manipulation is usually sufficient 

Fig. 126. 




Pushing the lower jaw forward. (Esmarch.) 



to reestablish the respiratory movements, but if so fortunate 
a result does not take place artificial respiration should be 
practised — Sylvester's or Howard's methods being given the 
preference — the patient's head being placed upon a lower 
level than the body, the tongue brought forward, and the 
fauces being cleared of mucus. The respiratory action 
should also be stimulated by the use of electricity — one 
sponge-electrode being placed over the sternum, the other 
being applied to the epigastrium during an inspiratory effort. 



ANESTHESIA. 199 

If artificial respiration is not satisfactorily applied in this 
way, forced respiration applied by means of a mask with 
tube and bellows attached (Fell's apparatus, see page 176), 
or an intubation-tube with a rubber tube attached, which is 
connected with a bellows, may be slipped into the larynx, 
and air may thus be directly forced into the lungs, or the 
trachea should be opened. This is especially to be recom- 
mended if the asphyxia has resulted from blood or vomited 
matters having entered the larynx. After opening the 
trachea and introducing a tracheal canula, a rubber tube 
and bellows is connected with this and respiratory move- 
ments are simulated by forcing air directly into the trachea. 

The hypodermic injection of strychnia, atropia, or digi- 
talis is also recommended, and the intravenous injection of 
ammonia is said to have been followed by good results. 

Efforts at resuscitation in these cases should be persevered 
in for at least half an hour, as apparently hopeless cases 
have been saved by persistent use of these means. 

The person intrusted with the administration of the anaes- 
thetic should watch the patient closely and should not have 
his attention diverted by the operation ; he should carefully 
watch the pulse, respiration, and the color of the patient's 
face, and be ready to withdraw the ether upon the develop- 
ment of any symptom of danger, and to meet such symptoms, 
should they arise, by the use of some of the means pre- 
viously mentioned. 

The administration of ether vapor by the rectum was a 
few years ago employed in many cases, and although anaes- 
thesia was quickly produced, dangerous symptoms sometimes 
followed its employment, so that this method of adminis- 
tration has been abandoned. 

An anaesthetic should never be given to a woman without 
the presence of a third person, as in some cases these agents 
give rise to erotic dreams, and it may be difficult to disabuse 
the patient's mind of the idea that an assault has been 
committed unless the evidence of eye-witnesses at the time 
of the anesthetization can be brought forward to prove 
that such was not the case. 



200 MINOR SURGERY. 



Chloroform. 

A patient is prepared for the administration of chloroform 
as in the case of ether, the same precautions being taken as 
regards the removal of false teeth or foreign bodies from the 
mouth, and to see that the clothing about the chest and 
neck does not restrict the circulation or respiratory move- 
ments. Chloroform is certainly a much more dangerous 
anaesthetic than ether, and although it is widely used in the 
British Islands and upon the Continent, it is not used in 
this country except in certain districts — as in the southern 
and southwestern districts of the United States, and here 
its use is followed by fewer fatalities than in the northern 
districts, so that it is possible that its use is safer in warm 
climates. Clinical experience has demonstrated the fact 
that chloroform can be used in aged and very young sub- 
jects and in puerperal patients with comparative safety; it 
is also to be preferred to ether in patients suffering from 
emphysema of the lungs, bronchitis, and vascular degener- 
ation of the kidneys. It is also employed instead of ether 
in operations upon the mouth when the actual cautery is 
employed, on account of its less inflammable character. 

Chloroform is administered by pouring a drachm of the 
drug upon a folded towel, which is first held a few inches 
from the mouth and nose and gradually brought nearer, but 
is not allowed to come in contact with the face, as from its 
local irritating action it will blister the surface ; the anses- 
thetizer should remember that one of the dangers in the 
administration of chloroform is the risk of too great con- 
centration of its vapor, so that he should see that a sufficient 
admixture of atmospheric air takes place. Profound anaes- 
thesia is evidenced by insensibility of the conjunctiva to the 
touch, by complete muscular relaxation, and by the absence 
of reflexes ; the pupils in chloroform -anesthesia are usually 
contracted. Various inhalers have been devised to regulate 
the amount of chloroform administered and to secure the 
proper admixture of atmospheric air, and the best of these 
is probably Mr. Clover's apparatus. (Fig. 127.) This 
consists of a bag holding 8000 cubic inches of air connected 



ANESTHESIA. 



201 



with a face-piece by a flexible tube. The bag is charged 
by means of a bellows (Fig. 127, 1) measuring 100 cubic 
inches ; and the air is passed through a box warmed with 
hot water, into which is introduced at each filling of the 



Fig. 127. 




Clover's chloroform apparatus. (Erichsex.) 

bellows as much chloroform as is required for 1000 cubic 
inches of air. This is done with a syringe (Fig. 127, 2) ; the 
amount of chloroform required is usually from 30 to 40 
minims. When the bag is full the tube is removed from 
the evaporator and the mouthpiece (Fig. 127, 3) is fitted to it. 
Additional air may be admitted by regulating the size of 
the opening in the mouthpiece ; the patient, however, can- 
not receive a larger proportion of chloroform than the air 
in the bag is charged with. 

Death from the administration of chloroform results from 
cardiac syncope or from respiratory arrest, and the dangerous 
symptoms develop so rapidly that the greatest promptness 
is required to meet them. The person administering chloro- 
form should be constantly on the watch, and should not for 
a moment have his attention diverted from the patient ; 
great vigilance is here, if possible, more important than 
during the administration of ether. 



202 MINOR SURGERY. 

When dangerous symptoms arise they are to be treated 
by lowering the patient's head, and if respiratory arrest has 
occurred the same means to bring about respiratory action 
should be employed as for a similar condition during ether 
narcosis. Cardiac syncope is treated by the use of electri- 
city, the electrodes with a rapidly interrupted current being 
swept over the chest ; hypodermics of digitalis and strych- 
nine and atropia may be employed to stimulate the heart 
and respiration, and as in ether narcosis the efforts should 
not be desisted from for some time, as by the persistent 
employment of these means apparently hopeless cases have 
been resuscitated. 

The A. C. E. Mixture. 

This mixture, which consists of 3 parts of chloroform, 
1 part of ether, and 1 part of alcohol, has been employed 
by some surgeons in the place of ether or chloroform, with 
the idea that the dangers of chloroform are diminished by 
the combination of it with ether and alcohol. Clinical 
experience, however, has not proved this view to be correct, 
and I see no advantage in the use of this combination over 
that of ether or chloroform. If administered with as much 
care as chloroform, its administration is accompanied with 
the same safety. It should be administered upon a towel 
in the same manner as chloroform, and the patient should 
be watched as carefully during its inhalation as during the 
administration of the latter drug, and complications occur- 
ring should be treated in the same manner as those arising 
during the use of chloroform. 

Trusses. 

A truss for the palliative treatment of hernia is a me- 
chanical contrivance with one or more pads and a strap ; 
these are held in position by a spring to which they are 
attached, which holds the pad in contact with the skin over 
the hernial ring. 



TRUSSES. 203 

They are applied in all cases of reducible hernia, and are 
used in the treatment of hernia at all ages ; in infants and 
young children the continued use of a properly fitting truss 
is often followed by a radical cure of the hernia. 

Trusses are made with steel or rubber springs and with 
pads of wood, rubber, celluloid, or horsehair, covered with 
chamois, and their shape and the pressure which they 
exert varies with the kind of hernia for which they are 
applied. 

A firm compress applied over the inguinal canal or crural 
ring, secured in position by a firmly applied spica-of-the- 
groin bandage, forms a very satisfactory temporary means 
of controlling either of these varieties of hernia. 

A properly fitting truss should be worn without discom- 
fort to the patient — that is, should not make too much 
pressure upon the skin at the points where the pads are 
applied — and should absolutely prevent the descent of the 
hernia. In testing the adequacy of a truss, after applica- 
tion, to prevent the escape of the hernia, the patient should 
be instructed to separate his legs, bend forward over the 
back of a chair, and cough or strain deeply ; if this does 
not bring the hernia down, its control of the rupture may 
be considered satisfactory. 

Trusses should be applied after the complete reduction of 
the hernia, while the patient is in the recumbent posture. 
When first applied the truss should be worn both during 
the night and day, and if the skin becomes tender at the 
points of pressure it should be sponged with alcohol and 
alum, then dried and dusted with powdered starch or lyco- 
podium. Patients at first sometimes complain of discomfort 
in wearing a truss, but they soon become accustomed to its 
presence. After a truss has been worn for some time its 
use at night while the patient is in bed may be dispensed 
with, but the patient should not remove it until he is in bed 
in the recumbent posture, and he should reapply it before 
he rises in the morning. In children it is better to have 
the truss worn continuously, and if it is removed for bath- 
ing the nurse should be instructed to place her finger over 
the ring to prevent the descent of the hernia until the truss 



204 MINOR SURGERY. 

is reapplied. In applying trusses to male children care should 
be taken not to make pressure upon an undescended testicle. 

Trusses for Inguinal Hernia. 

In measuring a patient for this form of truss the circum- 
ference of the body midway between the crest of the ilium 
and the great trochanter should be taken, and the distance 
from the symphysis pubis to the anterior superior spinous 
process of the ilium may also be given, as half of this dis- 
tance corresponds to the position of the internal abdominal 
ring. In reducible inguinal hernia the truss-pressure should 
be exerted upon the inguinal canal and directly backward. 




Truss for inguinal hernia. 



To control this variety of hernia a single-spring truss 
(Fig. 128) may be employed, or the use of a truss having a 
double spring with flat pads on each side of the spine 
attached to the springs, and a smaller pad over the inguinal 
canal on the unaffected side, with a full pad on the side of 



Fig. 129. 




Hood's truss. 



the hernia, will often be found most satisfactory. This, 
which is known as a Hood's truss, is one which will be found 



TRUSS FOR UMBILICAL HERNIA. 205 

a very satisfactory instrument both in inguinal and femoral 
hernia. (Fig. 129.) 

Trusses for Femoral Hernia. 

In measuring a patient for this variety of truss, the cir- 
cumference of the body midway between the crest of the 
ilium and the great trochanter should be taken ; the dis- 
tance of the saphenous opening from the symphysis pubis, as 
well as from the anterior iliac spine, should also be taken. 
In reducible femoral hernia the truss-pressure should be 
directed backward against the femoral canal, and the pad 
should be large enough to make pressure upon the adjacent 
tissues through which the hernia passes, as well as upon the 
relaxed tissues coverino- the femoral canal. As in inguinal 
hernia, either a single or a double spring truss may be em- 
ployed (Fig. 130). 

In applying a truss for femoral hernia, care should be 
taken to see that the pad does not rest upon the pubis, and 
thus remove the pressure from the crural ring and adjacent 
tissues and prevent the proper control of the hernia. 

Trusses for Umbilical Hernia. 

In measuring a patient for this variety of truss, the cir- 
cumference of the body over the umbilicus should be taken. 

Fig. 130. Fig. 131. 




Hood's truss for femoral hernia. Truss for umbilical hernia 



In reducible umbilical hernia the truss-pressure should be 
directed backward, and the pad should bear rather on the 
tendinous margins of the ring than on the hernial opening. 
A truss for this variety of hernia should have a flat or 

10 



206 MINOR SURGERY. 

slightly convex pad, which is held in position over the 
umbilical ring by means of springs having counter-pads on 
either side of the spine attached to their extremities ; these 
are fastened together by a strap (Fig. 131). 

A simple and satisfactory truss for umbilical hernia in 
infants consists of a penny covered by adhesive plaster, held 
over the umbilical ring by one or two strips of adhesive 
plaster about two inches in width, which should be applied 
so as to cover in about the anterior two-thirds of the body. 
A penny, or a small, flat compress of linen, will be found 
much more satisfactory than the conical rubber or cork pad 
which is often recommended. 



Trusses for Irreducible Hernia. 

The application of a truss to this variety of hernia secures 
the hernia from injury and prevents the further protrusion 
of the hernia ; such trusses are secured in the same way as 
those for reducible hernia, but the pads are made concave or 
cup-shaped, or may have an air-cushion attached to the pad. 



Use of Catheters and Bougies. 

Catheters are hollow tubes, made either of metal, India- 
rubber, or other flexible substances. 

Metallic catheters are made of silver, or, if constructed 
of other metals, they should be plated with silver or nickel, 
to give them a smooth, bright surface which can easily be 
kept perfectly clean; and their- shape should conform to 
that of the normal urethra (Fig. 132). The shape of the 
metallic catheter is sometimes changed to meet certain indi- 
cations ; for instance the metallic catheter for use in cases 
of enlarged prostate is longer and has a longer curve than 
the ordinary instrument (Fig. 133). The metallic female 
catheter is shorter and has a much smaller curve than the 
instrument used for the male urethra. 



USE OF CATHETERS AND BOUGIES. 



207 



Flexible Catheters. — The most commonly used variety of 
flexible catheter is that known as the English catheter, 
which is made of linen and shellac, and is provided with a 
stylet ; it can be moulded into any shape desired by dipping 



Fig. 135 



Fig. 133. 




Metallic catheter. 



Prostatic catheters. 



it into hot water, which renders it very flexible, and, after 
moulding it to the proper curve, this can be fixed by im- 
mersing it in cold water, which hardens it again. 

The French flexible catheters are made of India-rubber, 
or a combination of this material with other substances. 
These instruments are conical toward their extremities, and 



208 



MINOR SURGERY 



terminate in an olive-shaped point; they are provided with 
one or two smoothly finished eyes near their vesical extrem- 
ities (Fig. 134). 

Fig. 134. 



O 



o 



French flexible bougie and catheter. 

Another form of flexible catheter, known as the elbow- 
catheter or Mercier's catheter (Fig. 135), has an angle or 

Fig. 135. 



C WRIGHT Sc C LONDON 

Mercier's elbowed catheter. 

elbow near its vesical extremity ; this is often found a satis- 
factory instrument to use in cases of enlarged prostate. A 

Fig. 136. 




Soft rubber catheter. 



variety of flexible catheter made of soft India-rubber is 
also sometimes employed. (Fig. 136.) 



INTRODUCTION OF A CATHETER. 209 

Catheters and bougies are made according to a certain 
scale. The English scale runs from 1 to 12; the American 
from 1 to 20 ; and the French from 1 to 30. 

Bougies and Sounds. 

Bougies are flexible instruments which correspond in size 
and shape to the English and French catheters, and besides 
these is the acorn-pointed bougie (Fig. 137) and the filiform 
bougie, which is made of whalebone or of the same material 

Fig. 137. 

— ■ —€) 



Bulbous or acorn -pointed bougies. 

as the ordinary French bougie and catheter. These instru- 
ments are of very small size and can often be passed through 
strictures which will admit no other form of instrument. 
(Fig. 138.) 

Sounds. — These are solid instruments usually made of 
steel with a smooth surface and plated with nickel ; they 
correspond in size and have the same curve as the metallic 
catheter ; the handle is flattened to allow the operator to 
grasp them firmly ; they are employed in the treatment of 
strictures by dilatation. (Fig. 139.) The sound used in 
dilating strictures of the meatus is straight and is shorter 
than the sound employed in the treatment of urethral stric- 
tures. (Fig. 140.) 

Introduction of a Catheter. 

The passing of a catheter is a minor surgical procedure 
which every practitioner is at times called upon to employ, 
and its passage through a healthy urethra is a matter of 
little difficulty. For the introduction of a catheter the 
patient may be in the standing, sitting, or recumbent pos- 



210 



MINOR SURGERY. 



ture, and the latter is the best in most cases ; he should rest 
squarely on his back and have the thighs a little flexed and 
separated. 



Fig. 138. 



Fig. 139. 



Fig 140. 



i / 



6 4MR, C I 



m 



Filiform bougies. 



Steel sound. 



Sound for dilating meatus. 



Before passing a metallic catheter the surgeon should see 
that it is perfectly clean, and after warming and oiling it 
he stands upon the left side of the patient and grasps the 
penis with the left hand, and turns it over the pubis and 
introduces the beak of the catheter into the meatus, and 



INTRODUCTION OF A CATHETER. 



211 



gently passes it along the urethra until its point passes 
beneath the symphysis pubis ; at this point the handle is 
elevated and gently depressed between the thighs, and the 
beak will pass into the bladder. (Fig. 141.) 



Fig. 141. 




Introduction of catheter. (Voillemier.) 

When the prostatic region is reached difficulty is some- 
times experienced in passing the catheter ; this may be 
overcome by introducing the finger into the rectum and 
guiding the catheter through this, or if the prostate is found 
much enlarged the catheter should be withdrawn, and a 
prostatic catheter (Fig. 133) should be substituted for it. 

The same manipulation is made use of in passing metallic 
sounds. 



212 MINOR SURGERY. 

Flexible catheters and bougies are passed by grasping 
the penis and holding it in such a position that it is at a 
right angle to the axis of the body, and the catheter or 
bougie is passed into the meatus and carried through the 
urethra into the bladder by gently pushing the instrument 
downward. 

In this variety of catheter, which has no curve, the surgeon 
has no means of guiding the point of the instrument, and 
if an obstruction is met he should withdraw the instrument 
slightly and make another attempt ; all manipulations should 
be extremely gentle. 

The same manipulations are employed in passing bougies 
through the urethra. 

Passing the Female Catheter. 

This should be introduced without exposure of the patient, 
she being in bed with the thighs slightly flexed and sepa- 
rated from each other. The surgeon introduces the fore- 

Fig. 142. 




Method of holding female catheter. 

finger of the left hand between the nymphse, bringing it 
from behind forward until he touches the space between the 
entrance of the vagina and the orifice of the urethra ; the 
catheter is then introduced with the right hand held as 
shown in Fig. 142, and guided by the left forefinger is passed 
through the orifice of the urethra into the bladder. 



TYING MALE CATHETER IN BLADDER 



213 



Tying Male Catheter in the Bladder. 



Fig. 143. 



When it is desirable to retain a catheter for some time in 
the male bladder, it is necessary to secure it to prevent its 
slipping out. Either a metallic or flexible catheter may be 
employed, but, as a rule, the flexible instrument is to be 
preferred ; there are several methods of securing it in the 
bladder. 

By one method two narrow strips of tape, or two or three 
strong silk ligatures are attached to the rings at the end of 
a metallic catheter, or are securely fastened around the end 
of the flexible instrument ; these are next brought backward, 
one on each side of the penis, and the skin is drawn forward 
and a strap of adhesive plaster half an inch in width is 
passed over the strings or tapes 
and carried three or four times 
around the body of the penis 
just behind the position of the 
glans penis. If the skin has 
been brought well forward be- 
fore the straps have been applied, 
the ligatures are tightened as it 
slips back, and the catheter has 
not too much play (Fig. 143). 

Another method consists in 
fastening a strong silk ligature around the catheter just in 
advance of the meatus ; the two ends are next brought back- 
ward and tied in a knot behind the corona glandis ; the ends 
are then carried around behind the corona and tied on one 
side of the frsenum ; the foreskin is slipped forward and 
covers the ligatures. 

A simpler method of securing the catheter is to perforate 
the free end with a needle armed with a double ligature of 
silk or hemp ; the needle being removed, two loops are made 
of the proper length, and these are passed through the ends 
of a ' T-bandage, which is secured around the waist, the 
tails being brought up on either side of the scrotum and 

10* 




Tying in catheter. (Bryant.) 



214 



MINOR SURGERY. 



secured to the body of the bandage passing around the 
waist. 

In the female bladder, when it is desirable to keep the 
bladder empty, the self-retaining catheter is usually em- 
ployed, which consists of a catheter with a bulb at its vesical 
extremity, or an ordinary catheter with silk loops and a 
T-bandage may be employed in the same manner as in 
securing a male catheter. 

The Endoscope. 

This instrument is employed to explore the internal 
cavities of the body. When used to obtain a view of the 



Fig. 144. 




Endoscope of Desormeaux. 



WASHING OUT THE BLADDER. 215 

urethra, it consists of a straight conical metallic tube for 
the urethra, and for the bladder one which is somewhat 
curved like a vesical sound : there is also an eye-piece, an illu- 
minating apparatus, and an arrangement of mirrors by which 
a strong light can be thrown upon whatever touches the end 
of the tube (Fig. 144). By the use of this instrument the 
urethra and inner surface of the bladder can be examined 
by the eye. 

A view of the urethra may also be obtained by the use of 
the urethroscope, which consists of a straight, hard rubber 
tube provided with a rounded obturator which projects some- 
what beyond the end of the tube. The instrument is intro- 
duced into the urethra until the bladder is reached, when it is 
slightly withdrawn and the obturator is removed and a strong 
light is thrown into the tube from a head mirror or from an 
electric lamp, and as the tube is withdrawn various portions 
of the urethra are exposed to the view of the surgeon. 

Washing out the Bladder. 

This procedure may be required in the treatment of 
cystitis, and it is accomplished by passing a flexible catheter 
with a large eye into the bladder, or a double catheter may 
be employed. A syringe, or better a rubber bulb holding 
about a pint, having a nozzle and stopcock (Fig. 145), is 

Fig. 145. 




Rubber bag with stopcock, for washing out the bladder. 

filled with warm water, or with any medicated solution 
which is desired, and it is then attached to the free end of 
the catheter and the contents are gently injected into the 
bladder ; care should be taken that the bladder is not too 
much distended. When the desired amount of fluid has 



216 



MINOR SURGERY 



been injected, it is allowed to run out of the catheter, and 
the procedure may be repeated until the solution comes 
away perfectly clear. 

Care should be taken to see that the. bladder is perfectly 
emptied of the solution, and in cases of paralysis of the 
bladder gentle pressure should be made upon the abdomen 
over the pubis to accomplish this object. Solutions of boric 
acid, permanganate of potassium, and weak solutions of 
carbolic acid and of nitrate of silver are often employed in 
washing out the bladder in cases of chronic cystitis. 

Urethral Injections. 



Fig. 146. 



In the treatment of urethral inflammations the injection 
of medicated solutions is generally made use of, and as 
these injections are usually made by the patient himself, he 
should be shown or instructed how to employ them. A 
rubber syringe having a conical nozzle and hold- 
ing about two or three drachms is the best in- 
strument to employ for this purpose. (Fig. 146.) 
The syringe having been filled with the solution, 
and the patient sitting upon the edge of a hard 
chair, with the thighs separated, grasps the 
syringe between the thumb and middle finger of 
the right hand, the tip of the index finger rest- 
ing upon the end of the piston, and inserts its 
conical end from a quarter to half an inch 
within the meatus, which is held open by the 
thumb and finger of the left hand, and after its 
introduction it should be drawn tightly around 
it, the pressure being made laterally so as to 
narrow the aperture instead of broadening it, as 
is the case when the compression is in an antero- 
posterior direction. After the fluid has been 
thrown into the urethra in this manner the 
syringe is removed, and the patient is instructed 
to hold the lips of the meatus together for one or two min- 
utes to prevent the escape of the fluid. 




Shape of 
nozzle of 
urethral 
syringe. 



SUTURES. 217 



Sutures. 



A variety of materials are employed for sutures, such as 
silk, catgut, silver or iron wire, silkworm-gut, and horse- 
hair ; the material most frequently employed at the present 
time is either catgut, silk, or silkworm-gut, although some sur- 
geons still prefer silver wire. Catgut is practically the only 
substance employed as a suture w T hich is absorbable ; the 
other varieties of suture require removal after their applica- 
tion, although some sutures, such as the silk, when employed 
in subcutaneous wounds may be cut short, as they are apt 
to become encysted and produce no trouble. It matters 
little what variety of material be employed for suture if the 
surgeon is careful to see that it is rendered thoroughly 
sterile before being brought in contact with the wound. 

Sutures of Relaxation are those which are entered and 
brought out at some distance from the edges of the wound, 
and are employed to prevent dangerous tension upon the 
sutures which close skin wounds. This form of suture is 
employed by the use of the quilled, button, or plate suture. 

Sutures of Coaptation. — These are superficial sutures 
applied closely together and include only the skin ; they 
are employed to secure accurate apposition of the cutaneous 
surface of wounds. 

Sutures of Approximation are those which are applied 
deeply into the tissues to secure approximation of the deep 
portions of a wound; this object is accomplished by the use 
of the quilled, button, or plate suture. 

Secondary Sutures. — These sutures are applied when the 
surfaces of the wound are covered by granulations, when the 
primary sutures have failed to secure apposition of the edges 
of the wound, or in cases of secondary hemorrhage where the 
opening of the wound has been necessitated to turn out the 
blood-clot and secure the bleeding vessel, or in plastic opera- 
tions where the primary sutures have failed to secure ad- 
hesions of the edges of the flaps. They are also employed 
with advantage in cases in which it is necessary to pack a 
wound with antiseptic gauze, or to allow haemostatic forceps 



218 



MINOR SURGERY 



to remain clamped upon bleeding tissues in a wound at the 
time of operation. The sutures should in such a case be 
introduced and loosely tied at this time, and when the 
packing or forceps are removed at the end of two or three 
days the sutures are tightened so as to secure apposition of 
the edges of the wound. 

Surgical Needles. 

Needles for surgical use are of different sizes and shapes 
(Fig. 147) ; straight needles are the ones most commonly 

Fig. 147. 




Surgical needles. 

employed, but curved needles will be found most conven- 
ient for the introduction of sutures in wounds of certain 

Fig, 148. 




Mounted needle. 



locations. Tubular needles are often employed in introduc- 
ing sutures in wounds in which the use of an ordinary 



SECURING SUTURES AND LIGATURES. 219 

needle is difficult : for instance, in the operation for cleft 
palate, and for the introduction of sutures in deep wounds, 
a mounted needle will often be found very useful (Fig. 
148). Needles should be sharp and clean and should 
be rendered thoroughly aseptic before being used. A 
needle-holder is often required for the satisfactory introduc- 
tion of needles in wounds of certain localities (Fig. 149) ; if 

Fig. 149. 




Needle-holder. 



this is not at hand the needle may be held by a pair of 
dressing forceps or a pair of haemostatic forceps. 

Method of Securing Sutures and Ligatures. 



Metallic sutures are usually secured by twisting the ends 
together or by passing the ends through a perforated shot 
and clamping the shot with a shot-compressor, which se- 
curely fixes them. 

Sutures and ligatures of catgut, silk, silkworm-gut or 
horsehair are secured by tying, and several different knots 
are employed to secure them. 

Reef or Flat Knot. 

This is one of the best forms of knot to use in securing 
sutures or ligatures, and it is made by passing one end of 
the thread over and around the other end, and the knot 
thus formed is tightened ; the ends of the thread are next 
carried toward each other and the same end is again carried 
over and around the other, and when the loop is drawn 
tight we have formed the reef or flat knot (Fig. 150). 



220 



MINOR SURGERY 
Fig. 150. 




Reef or fiat knot. 

Surgeon 8 Knot. 

This knot is formed by carrying one end of the thread 
twice around the other end (Fig. 151) ; and after tighten- 

Fig. 151. 




Surgeon's knot. 

ing this loop the same end is carried over and around the 
other end as in the case of the final knot of the reef or flat 

Fig. 152. 




Surgeon's knot and reef knot combined 



knot. The surgeon's knot and reef knot combined is one 
of the best methods of securing sutures or ligatures of 



SECURING SUTURES AND LIGATURES. 221 



catgut or silk, as the first knot is not apt to relax before 
the second knot is applied. (Fig. 152.) 

Granny Knot. 

This method of tying the ligature or suture should not 
be employed, as the resulting knot is not as secure as the 
reef knot and is apt to relax ; it differs from the latter in 
the fact that one end of the thread having been carried 

Fig. 153. 




Fig. 154. 



Granny knot. 

across and around the other end, the knot is completed by 
carrying the same end under and around the other end of 
the thread (Fig. 153). 

The Staffordshire knot, which is much used to secure the 
pedicle in the removal of the ovaries or ovarian tumors, is 
applied as follows : A handled-needle 
armed with a stout silk ligature is 
passed through the pedicle, and then 
withdrawn so as to leave a loop on 
the distal side ; this loop is drawn 
over the ovary or tumor and one of 
the free ends is passed through it so 
that one end is above while the other 
end is below the retracted loop. (Fig. 

154.) The ends are then seized and drawn through the 
pedicle ; at the same time the thumb and forefinger are 
pressed against it, until sufficient constriction is made, and 
the ends are finally secured by tying as in the securing of 
an ordinary ligature. 




Staffordshire knot. 



222 



MINOR SURGERY. 



Varieties of Suture. 

The Interrupted Suture, 

This variety of suture is the one most usually employed 
in the apposition of wounds, consisting of a number of single 
stitches, each of which is entirely independent of those on 
either side. In applying this suture the surgeon holds the 
edge of the wound with the fingers or forceps and thrusts 
the needle, previously threaded, through the skin three or 
four lines from the edges of the wound. He then passes the 



Fig. 



The interrupted suture. 



needle from within outward through the tissues of the oppo- 
site flap at the same distance from the edge of the wound. 
(Fig. 155.) Each stitch is secured as soon as it is passed — 
by tying if a silk, catgut or silkworm-gut suture be used, or 
by twisting if a silver- wire suture is employed. A suture may 
be used with a needle threaded on each end, and in this case 
both needles are passed from within outward. The sutures 
may be secured as soon as applied or they may be left un- 
secured until a sufficient number have been introduced and 
then they may be secured by tying or twisting. Care 
should be taken to see that they make no tension on the 



VARIETIES OF SUTURE. 



223 



edges of the wound and that they are so introduced as to 
make the best possible apposition of the parts. 

In extensive and deep wounds it may be found necesary 
to introduce both deep and superficial sutures, the former 
bringing about apposition of the muscles and deep fascia, 
the superficial layer bringing together the superficial fascia 
and skin. 

The deep or burled sutures are often employed to unite 
fascia, muscles or tendons, and the best material for this 
variety of suture is either catgut or silk. 

Continued or Glover s Suture. 

This variety of suture is applied in the same manner as 
the interrupted suture, but the stitches are not cut apart 

Fig. 156. 




Continued or sdover's suture: method of securing. 



and tied : it is made with silk or catgut, and is secured by 
drawing it double through the last stitch and using the free 
end to make a knot with the double portion attached to the 



224 



MINOR SURGERY. 



needle. (Fig. 156.) This suture is generally employed in 
intestinal sutures, but may also be employed in bringing about 
apposition of the edges of wounds in tissues of loose structure. 

The Twisted or Hare-lip Suture. 

This is a very useful form of suture where great accuracy 
and firmness of apposition of the edges of the wound are 
desired. It is applied by thrusting pins or needles through 
both lips of the wound, the edges being kept in contact 
over the wound by figure-of-eight turns with silk or wire. 
(Fig. 157.) The ends of the pins should be cut off by pin- 
cutters after the sutures are applied, or should be protected 
by pieces of cork or plaster to prevent them from injuring 
the skin of the patient and causing him pain. 

The India-rubber Suture. 

This is applied by first passing the pins or needles through 
the edges of the flaps, and instead of the twisted figure-of- 



Fig. 157. 



Fig. 158. 





Twisted or hare-lip suture. 



India-rubber suture. 



eight suture of silk, delicate rings of India-rubber are 
employed. (Fig. 158.) 

The twisted or hare-lip suture is frequently employed in 
plastic operations about the face and in other parts of the 
body, where accurate apposition of the flaps is desired. 

The Quilt Suture. 

This variety of suture is made with silk or catgut, and is 
employed in wounds to effect very close approximation of 



VARIETIES OF SUTURE, 



225 



the parts and to prevent bagging ; it is often employed in 
connection with the continued suture, and is applied as 
shown in Fig. 159. 

Fig. 159. 




The quilt suture. 

The Quilled Suture. 

In making use of this suture a needle armed with a 
double thread of wire or silk is passed through the tissues 
as in applying the interrupted suture, but at a greater dis- 
tance from the edges of the wound. Into the loops on one 
side of the wound is inserted a quill or piece of a flexible 
catheter or bougie, and on the opposite side the free ends 
of the sutures are tied around a similar object after being 
tightened. (Fig. 160.) This form of suture makes deep 
and equable pressure along the whole line of the wound. 
In applying this suture it may be found well in some cases to 
introduce a few superficial interrupted sutures along the line 
of the wound to secure accurate approximation of the skin. 



226 



MINOR SURGERY. 



This form of suture was formerly much employed in cases 
of deep wounds to secure accurate apposition of the deep 



Fig. 160. 




Fig. 161. 



The quilled suture. (Smith.) 

portions of the wound, but recently the introduction of 
buried catgut sutures has supplanted the use of this variety 
of suture. 

Button or Plate Suture. 

This suture is applied by passing a needle armed with a 
double thread as in the case of the quilled suture, the ends 
of the suture being passed through the 
eyes of a button or through perforations in 
a lead plate before being threaded in the 
eye of the needle. After the suture pre- 
pared in this way has been passed through 
both sides of the wound, the needle is re- 
moved and the free ends of the suture are 
passed through the eyes of a button or 
the perforations in a lead plate on the 
opposite side of the wound, and are tight- 
ened and secured. (Fig. 161.) This form 
of suture may be employed in deep wounds 
to accomplish the same purpose as the 
quilled suture, and allows the cutaneous 
margins of the wound to remain free from compression, and 
here, as in the case of the quilled suture, a few interrupted 




Button suture. 
(Smith.) 




VARIETIES OF SUTURE. 227 

sutures may be introduced between the button or plate 
sutures to secure accurate apposition of the skin surfaces if 
desired. 

Tongue-and-groove Suture. 

This variety of suture, devised by the late Dr. Joseph 
Pancoast. consists in slipping the margin of the flap which 
has been bevelled into a groove, 
made by dissecting up the margin 
of the skin surrounding the raw 
surface which is to be covered. 
In applying this suture the wire 
or thread used has a needle ap- 
plied on each end, and after 
passing the sutures so as to m , ' 

r in o i Tongue-and-groove suture. 

secure the naps the tree ends 

are secured over a pad of adhesive plaster or a disc of lead 

or a button. (Fig. 162.) 

Shotted Sutures. 

This suture receives its name not from any special method 
of application, but solely from the way in which it is secured ; 
any of the previously mentioned varieties of sutures may 
be employed. The material used in applying this suture 
may be catgut, silver wire, silkworm-gut, silk, or horsehair, 
and after the suture has been passed the needle is removed, 
and the ends are passed through a perforated shot ; the ends 
are then drawn upon to bring the edges of the wound in 
contact, and the shot is pressed down to the skin and 
clamped by means of a shot- compressor. The suture is 
then cut off flush with the surface of the shot. 

This method of securing sutures is especially useful in 
closing wounds in the mucous cavities, such as the va- 
gina, rectum, and mouth, where the knot or twist of the 
wire might cause irritation of the surface or pain to the 
patient ; it is also a useful method of securing sutures in 
plastic operations; it also facilitates the removal of the 
sutures, as the shot is not apt to be obscured by the swollen 



228 MINOR SURGERY. 

tissues and is easily seized by forceps when the loop is 
divided. 

Removal of Sutures. 

Where sutures are buried in the tissues or used to ap- 
proximate parts in cavities which are subsequently closed, 
such material should be used for sutures as will be absorbed 
in a few days, or will become encysted and remain harmless 
in the tissues — such as catgut, silkworm-gut, or silk — and 
it is needless to state that sutures used with this end 
in view should be rendered perfectly aseptic before being 
employed. 

Catgut sutures, when well prepared and used for sutures 
in external wounds, usually undergo absorption in from ten 
to fifteen days ; the loop buried in the tissues is absorbed 
and the knot may be removed from the surface with forceps 
or comes off with the dressings. 

The other substances, such as silk, silkworm-gut, silver 
wire, and horsehair, are removed by cutting one side of the 
loop and making traction upon the knot of the suture with 
forceps, or in the case of the wire suture, after dividing the 
loop and straightening out one end of it, the wire should be 
withdrawn in a curved direction. 

Sutures which are not causing any irritation should be 
allowed to remain in position until the wound is solidly 
healed. The time usually required for their retention in 
cases of aseptic wounds is from eight to twelve days. 

Lembert's Suture. 

Lembert's suture is used in wounds of the viscera covered 
by the peritoneum, with the object of bringing in contact 
the peritoneal surfaces. This form of suture is usually 
employed in closing wounds of the intestine or stomach. 
(Fig. 163.) 

A needle armed with a fine catgut or silk thread is passed, 
and it is better to employ a round needle, such as the ordi- 
nary sewing-needle, in preference to the bayonet-pointed 
needle, as there results by its use less bleeding from the 



VARIETIES OF SUTURE 



229 



punctures. The needle is first carried through the peri- 
toneal and muscular coats of the intestine a short distance 
from the wound, and it is then carried across the wound 



Fig. 163. 




Lembert's suture. 


(Bryant. 


Fig. 164. 






s: 



Lembert's suture, a, serous ; b, muscular; and c, mucous coat. (Smith.) 



and passed through the same portions of the intestine a 
short distance from the edge of the wound on the opposite 
side, and when the suture is tightened the peritoneal sur- 
faces of the intestine are inverted and brought into contact 
with each other (Fig. 164) ; the interrupted or continued 
suture may be employed in making this form of suture. 

Gely's Suture. 

In applying this form of suture in intestinal wounds a 
ligature armed with a fine needle at each end is employed, 

11 



230 



MINOR SURGERY, 



and the punctures should be about five millimetres apart ; 
the method of applying the suture is shown in Fig. 165. 



Fig. 165. 





Gely's suture. 

Bouissons Suture. 

This method of suturing intestinal wounds, which is more 
complicated than either of the previously mentioned methods 
and possesses no advantage over them, is applied by passing 




Bouisson's suture. 



a delicate pin in and out along each side of the wound as 
shown in Fig. 166, and drawing them together laterally by 
ligatures passed through the intervals, one end of each 
ligature being cut short and the other end being brought 



VARIETIES OF SUTURE. 



231 



out at the lower angle of the external wound ; a thread is 
also tied under the head of each pin and brought out at the 
upper angle of the wound, and at the end of three or four 
days the pins are removed by means of the threads 
attached to them, and at the same time the sutures, having 
been freed by the removal of the pins, are withdrawn. 

Czerny Suture. 

This suture is applied in intestinal wounds by passing the 
needle armed with a catgut or silk thread through the 
serous membrane on one side of the wound of the intestine 
and out at the wound surface so as not to include the 
mucous membrane ; the needle is then passed through the 
wound surface on the opposite side, avoiding the mucous 
membrane, and brought out through the serous membrane 
a short distance from the edge of the wound." By this 
suture the lips of the wound are approximated. For addi- 
tional security in preventing the escape of the contents of 
the intestine and to secure approximation of the serous sur- 
faces a few Lembert sutures should be introduced. 

Joberfs Suture. 

This suture which was employed in transverse wounds of 
the intestine which completely or incompletely divided the 



Fig. 167. 




Jobert's suture. 

gut, is introduced after turning the lower end of the bowel 
in upon itself. When the division of the gut was incom- 



232 



MINOR SURGERY. 



plete he employed only one suture, when complete two ; the 
ends of the sutures were brought out of the external wound. 
(Fig. 167). By this method of suture the two serous sur- 
faces are brought into contact. 

Sutures Employed in Intestinal Anastomosis. 

When it is desired to form a permanent orifice between 
two portions of the gut, the ends of the gut are closed and 
an opening is made in each portion of the gut and the walls 



Fig. 168. 




Method of applying Senn's decalcified bone plates. (Greig Smith.) 

of the gut surrounding the openings are held in contact with 
each other by sutures attached to perforated plates of decal- 
cified bone ; this is the method devised by Senn. The 
manner of using the bone plates and sutures is shown in 
Figs. 168 and 169. To accomplish the same purpose 



VARIETIES OF SUTURE 



233 



rubber rings or perforated plates of rubber have been em- 
ployed, also rings made from catgut, to which the sutures 
are attached, are applied in the same manner as Senn's 
plates. In using the rubber rings or plates it is well to 
divide them at one or two points and unite them by catgut 
sutures which will soften and be dissolved in a few days and 
allow the ring or plate to change its shape and facilitate its 
passage through the bowels ; if catgut rings are employed 
these will be softened and dissolved in a short time so as to 
be passed without difficulty. Intestinal anastomosis may be 

Fig. 169. 



INTESTINE 




WAUL OF 
INTESTINE 
TURNED IN AND 
SECURED BY 
LEMBERT STITCHESll 




SECTION OF RING 



SECTION OF RING 

INTESTINE 




Diagram showing position of bone plates in intestinal anastomosis after 
resection of the bowel. (Roberts.) 

employed instead of Jobert's suture or the circular suture in 
wounds completely dividing the intestine and after resection 
of the gut for the removal of growths or for stricture. 



Sutures Employed in Gastrostomy. 

In this operation, when the wall of the stomach has been 
exposed, two hare-lip pins should be thrust through the in- 
tegument and tissues near the edge of the wound and then 
through the peritoneal and muscular coats of the stomach, 
to bring the surface of the stomach in contact with the peri- 
toneum covering the inner surface of the abdominal walls in 
the region of the wound ; a few sutures of silk may also be 



234 



MINOR SURGERY. 



introduced to secure the wall of the stomach to the edges of 
the wound. The opening of the stomach is postponed for 
four or five days if possible, until the adhesion between its 
walls and the abdominal parietes is secure, and at this time 
the sutures and the pins are removed. 

When immediate- opening of the stomach is required for 
any reason, after the wall of the stomach has been exposed 
two silver wire sutures are passed through the peritoneal 
and muscular coats of the stomach by means of a needle ; 



Fig. 170. 




utures for immediate gastrostomy. (Roberts.) 



these sutures should be placed transversely to the external 
abdominal wound and serve to draw the wall of the stomach 
contact with the inner margins of the abdominal inci- 



m 

sion. 



A long silk suture is next passed through the outer coats 
of the stomach so that the loops project upon the external 
surface of the organ (a). A needle, having a hook near 
its extremity (<?), is passed through the abdominal wall and 
engages the loop and draws it to the surface of the abdomen 



LIGATURES USED IN VASCULAR GROWTHS. 235 

near the edge of the abdominal wound ; the same manipula- 
tion is repeated until all of the loops have been brought to 
the surface. (Fig. 170.) 

A piece of rubber tube is carried around the external 
wound and slipped through the loops which project upon 
the surface of the abdomen (c), and by drawing the loops 
tight over the rubber tube and tying the ends of the suture 
the stomach wall is secured in contact with the inner mar- 
gins of the abdominal wound, and it may be safely opened 
after being thus fixed. 

In the operation of gastrotomy, where the stomach has 
been exposed and opened and the foreign body removed, or 
its cavity has been explored, or its orifices dilated as the 
case may be, the wound in the wall of the stomach is 
closed with Lembert's sutures, silk or catgut being the 
material employed for sutures. The abdominal wound is 
next closed with deep sutures which include the parietal 
peritoneum. 

Ligatures Used in the Treatment of Vascular 
Growths. 

Various forms of ligature are used for the strangulation of 
vascular growths ; the material used for ligatures is usually 
strong silk or hemp thread, catgut, or silver wire. 

The Single Ligature with Pin. 

This is applied by first inserting a hare-lip pin through 
the skin near the edge of the growth, passing it under the 
growth and bringing its point out through the skin at a point 
opposite the point of entry ; a strong silk or hemp ligature, 
which has been well waxed, is passed under the ends of 
the pin surrounding the base of the tumor and is drawn 
tight enough to strangulate the growth, and is secured by 
two knots (Fig. 171). If the growth is of considerable 
size it is better before applying this ligature to introduce a 
second pin at right angles to the first one, and then secure 
the ligature under the pins. In applying these forms of 



236 MINOR SURGERY. 

ligatures to healthy skin, the patient is saved much pain, 
and the separation of the mass is hastened, by cutting a 
groove in the skin with a sharp knife at the point where 

Fig. 171. 




Vascular tumor strangulated with pin and ligature. (Roberts.) 

the ligature is to be applied ; the ligature when tied is buried 
in the groove thus made. 

Double Ligature in Vascular Growths. 

This ligature is applied by passing a needle or a needle 
with a handle, armed with a double ligature, through the 
skin near the growth, and then passing it under the tumor 
and bringing it out through the skin at a point directly 

Fm. 172. 




Method of applying double ligature. (Roberts.) 

opposite the point of insertion ; the ligature is then divided 
and the needle removed and the tumor is strangulated by 
tying firmly the corresponding ends of the ligature on each 
side of the tumor, each ligature strangulating one-half of 
the growth (Fig. 172). 

The double ligature may also be applied by first passing 
a pin under the growth and then passing a needle armed 



LIGATUKES USED IN VASCULAR GROWTHS. 237 

with a double thread under the tumor at right angles to 
the pin, and after removing the needle the ends of the liga- 

Fig. 173. 




Method of applying double ligature and pin. (Bryant.) 

ture are tied and the tumor is strangulated in two sections 
(Fig. 173). 

Quadruple Ligature. 

In applying this ligature two needles carrying a double 
ligature are passed under the growth at right angles to each 
other, or if the handled needles be used they may be first 
passed in this manner, and then threaded with double liga- 
tures, which are carried under the growth as they are with- 
drawn. The needles being removed, the surgeon ties two 
ends of the ligature together and repeats this procedure 
until the growth has been strangulated in four sections. 
(Fig. 174.) 

Subcutaneous Ligature. 

This is applied by introducing a needle armed with a 
ligature through the skin near the growth, and carrying it 
through the subcutaneous tissues around the growth for a 

11* 



238 MINOR SURGERY. 

short distance, then bringing it out through the skin. The 
needle is again introduced through the same puncture and 
is again brought out through the skin at some distance from 

Fig. 174. 




Method of applying quadruple ligature. (Liston.) 

the first point of exit, and is next introduced through this 
puncture and brought out at a more distant point. In this 
way the growth is completely encircled by a subcutaneous 
ligature, which finally is brought out at the point of en- 
trance ; the tumor is strangulated by firmly tying together 
the ends of the ligature. (Fig. 175.) 

If a needle armed with a double ligature is first passed 
under the growth the ligature is divided, and by passing 
each end of the divided ligature subcutaneously around the 



LIGATURES USED IN VASCULAR GROWTHS. 239 

growth it may be strangulated subcutaneously in two sec- 
tions. 

Fig 175. 




Method of applying subcutaneous ligature. (Holmes.) 

Ericlisens Ligature. 

This ligature is employed to strangulate tumors of irregu- 
lar shape in a number of sections. A strong silk or hemp 
ligature three yards in length, one-half of which is stained 



Fig. i; 




Method of applying Erichsen's ligature. (Erjchses.) 



240 MINOR SURGERY. 

black, is carried by a needle as a double ligature under the 
growth at various points so as to leave a series of loops 
about nine inches long on each side of the tumor (Fig. 176) ; 
the black loops being cut on one side, the white on the 

Fig. 177. 



Erichsen's ligature applied. 

other, the ends are then firmly tied so as to strangulate the 
growth in sections. (Fig. 177.) 



Elastic Ligatures. 

Ligatures made of India-rubber varying from half a line 
to several lines in thickness are often made use of in surgery. 
They may be employed to strangulate growths such as 
moles or naevi, or in the treatment of fistulse, and are 
especially useful in the treatment of those cases of fistula- 
in-ano in which the internal opening into the bowel is 
situated high up, as the division of such fistulse by this 
means is accomplished without hemorrhage and with less 
risk than by the employment of the knife. In applying 
elastic ligatures in such cases the ligature, after being passed 
through the fistula by means of a probe, is carried out 
through the internal opening ; the anus is next well stretched, 
and the elastic ligature is then firmly tied with two or three 
knots ; the greater the tension made before the ligature is 
tied the more rapidly will it cut its way out. The smaller 
sizes of rubber drainage-tubes may be substituted for the 
solid rubber ligatures. 



CONTROL OF ARTERIAL HEMORRHAGE. 241 



Treatment of Hemorrhage. 

The surgeon may be called upon to treat the following 
varieties of hemorrhage : arterial, venous, or capillary ; and 
these again are classified according to the time of their 
occurrence, as — primary, that is, bleeding which occurs at 
the time the wound is inflicted ; intermediary or consecutive, 
that which occurs within twenty-four or forty-eight hours 
after the reception of the injury, which generally takes 
place during the period of reaction ; and secondary, which 
takes place after forty-eight hours, and may occur at any 
time subsequent to this period until the wound is healed. 
The treatment of hemorrhage is either constitutional or local. 

The constitutional treatment of hemorrhage consists in 
keeping the patient in the recumbent posture and avoiding 
any sudden elevation of the head or arms which might in- 
duce fatal syncope. Opium is a valuable remedy and should 
be freely used. Ergot, gallic acid, acetate of lead and tinc- 
ture of iron may also be employed, and stimulants and food 
should be carefully administered, and in extreme cases auto- 
transfusion or transfusion of blood or normal salt solution, 
as described on page 168, may be resorted to. 

In the local treatment of hemorrhage various measures 
may be adopted which may be either temporary or perma- 
nent in their action. 

Temporary Control of Arterial Hemorrhage. 

This may be effected by pressure applied directly to the 
bleeding vessel in the wound or by pressure applied indi- 
rectly to the main artery between the point of its injury 
and the centre of the circulation, and this pressure may be 
made by the fingers, digital compression, by compresses, or 
by means of tourniquets. 

Digital Compression. 

This constitutes one of the most valuable means employed 
in the temporary control of hemorrhage ; the finger is pressed 



242 MINOR SURGERY. 

directly upon the bleeding vessel in the wound or is used to 
make pressure upon the artery from which, the bleeding 
arises at some point between the wound and the centre of 
the circulation. (Fig. 178.) Control of hemorrhage by 
digital presssure can only be maintained for a few minutes, 




ital compression of the femoral artery. 



for the fingers of the surgeon or assistant soon become tired, 
so that it is only employed until means are adopted for the 
permanent control of the bleeding. Digital compression of 
the radial and ulnar arteries is frequently resorted to for the 
control of hemorrhage during amputations of the fingers, also 
of the axillary and femoral arteries in amputations at the 
shoulder- and hip-joints. 

It is also used to control hemorrhage from wounds either 
the result of accident, or those made by the knife of the 
surgeon, in which case the finger is placed directly upon the 
divided vessel, or employed to hold a sponge or compress 
firmly in the wound. 

Compresses. 

By the use of compresses placed directly in the wound or 
applied to the vessel between the wound and the centre of 
the circulation, the temporary control of hemorrhage may be 
very satisfactorily accomplished. Where it is possible, the 
compress which is applied in the wound should be made of 



CONTROL OF ARTERIAL HEMORRHAGE. 243 



antiseptic gauze, thereby diminishing the chances of wound- 
infection. 

The compress should be held in position by a bandage 
firmly applied and is generally employed only as a tem- 
porary expedient until a more permanent means of con- 
trolling the bleeding is adopted. 

Tourniquets. 

These instruments, which are employed for the temporary 
control of hemorrhage from wounds, are of many different 
kinds. 

Fig. 179. 

G&tVlR/r, <U SON 




Petit's tourniquet. 



Petit's tourniquet, which is the best for ordinary use, 
consists of two metal plates connected by a strong linen or 
silk strap, with a buckle — the distance between the plates 
being regulated by a screw. (Fig. 179.) In applying this 
tourniquet a compress or roller bandage is placed directly 
over the artery to be compressed and may be held in posi- 
tion by a few turns of the roller bandage. The lower plate 



244 



MINOR SURGERY. 



of the tourniquet is placed directly over this pad and the 
strap is tightly secured around the limb to keep the instru- 
ment in place. The screw is then turned so as to separate 
the plates and tighten the strap, thus forcing the compress or 
pad upon the artery controlling its circulation. This in- 
strument is very generally employed for the control of 
hemorrhage in wounds of the extremities and is especially 
useful in amputation of these parts, being placed over the 
main artery some distance above the seat of operation. 



Fig. 180. 



The Spanish Windlass. 

An improvised tourniquet, known as the Spanish windlass, 
may be employed in cases of emergency ; it is prepared by 

folding a handkerchief or piece of 
muslin into a cravat and placing 
a compress or smooth pebble on 
the body of the cravat ; this is 
placed over the artery to be con- 
trolled, and the ends of the hand- 
kerchief are tied loosely around 
the limb ; a short stick is passed 
through this loop, and by twisting 
the stick the loop is tightened and 
the compress is forced down upon 
the artery (Fig. 180). 

Many other forms of tourniquet 
have been devised which have the 
pad and counter-pad arranged as 
to make pressure upon the vessel 
desired, such as Lister's aorta 
compressor (Fig. 181), which is 
employed in the treatment of 
aneurism of the iliac vessels, and 
for the control of hemorrhage 
in amputation at the hip-joint. 
Hoey's clamp (Fig. 182) and 
Signorini's tourniquet (Fig. 183) are constructed upon the 
same principle, and are frequently employed to control the 




The Spanish windlass. 



CONTROL OF ARTERIAL HEMORRHAGE. 245 

Fig. 181. 




Lister's aorta compressor. 

circulation in the femoral artery in cases of operations on 
the thigh and leg, and in the treatment of femoral or pop- 
liteal aneurism. 



Fig. 182. 



Fig. 183. 





Hoey's clamp. 



Signorini's tourniquet. 



246 MINOR SURGERY. 

The elastic tube, or strap of Esmarclis apparatus (Fig. 
184) may also be employed for the temporary control of 
arterial hemorrhage, being applied above the wound, and if 
this is not at hand, any strong rubber cord, or a piece of 
large-sized drainage-tube may be used as a substitute. In 
hemorrhage from wounds of the hands and feet, especially 
in children, and in controlling hemorrhage from wounds of 
the penis, a piece of drainage-tube, firmly applied above the 
wound, may be employed with advantage. This tube or 

Fig. 184. 




Elastic strap of Esmarch's apparatus. 

strap, although generally employed to control hemorrhage 
from vessels of the extremities, may be used to control the 
femoral artery as it crosses the brim of the pelvis, by placing 
a compress over the artery in this position, and then apply- 
ing the elastic band to secure it with a figure-of-eight turn, 
passing it under the thigh, crossing over the pad, and then 
carrying the ends around the pelvis, and securing them. 

To make pressure on the axillary artery, a compress 
should be placed in the axilla, and the middle of the tube 
is placed over this to hold it in position ; the ends of the 
tube are then carried over the shoulder and crossed, and 
then carried to the opposite axilla and secured. 

In amputation at the shoulder-joint, to make pressure 
upon the subclavian artery, which is difficult to compress by 
an ordinary tourniquet, the handle of a large key well 
padded may be used ; it is firmly pressed against the 
vessel above the clavicle, and held by an assistant, and 



ESMARCH S BANDAGE AND TUBE 



247 



will prove a very satisfactory means of controlling the cir- 
culation in this vessel. 



Hemostatic Forceps. 

The temporary control of arterial hemorrhage by the 
use of haemostatic forceps is now very generally employed 
in surgical operations, and their use has done much to 
diminish the shock following 
operations from the loss of Fig. 185. 

blood. The haemostatic for- 
ceps in general use is self- 
retaining: it is clamped upon 
the bleeding vessel, and is 
allowed to remain until the 
operation is completed, when 
the vessel is secured perma- 
nently by the application of 
a ligature, and the forceps is 
removed. The use of these 
forceps will be found very 
satisfactory in controlling 
hemorrhage during the re- 
moval of tumors and in cases 
of amputation, and for the 
temporary control of bleed- 
ing during the operation of 
tracheotomy they will be 
found most efficient, as also 
in abdominal operations, in 
which their utility was first 
demonstrated. (Fig. 185.) Haemostatic forceps 




Esmarch's Bandage and Tube. 



This apparatus, which is applied to the limbs to render 
them bloodless during operations, consists of a rubber band- 
age two and a half inches in width and three or four yards 
in length, and a rubber tube two yards in length, to one end 



248 



MINOR SURGERY. 



of which is attached a chain and to the other a hook, or 
better a rubber strap, one inch in width and one and a half 
yards in length with a hook and chain. The bandage is ap- 
plied to the extremity of the limb and is carried up the 
limb to a point some distance above the seat of proposed 
operation ; the bandage is applied firmly, each turn overlap- 
ping one-fourth of the preceding one, and when the last 
turn has been made the rubber tube or strap is wound firmly 
around the limb and secured by fastening the hook into one 
of the links of the chain. (Fig. 186.) After securing the 
tube or strap the rubber bandage is removed from the limb 

Fig. 186. 




Esmarch's bandage and tube applied. 



and if the tube has been firmly enough applied the limb will 
be found to be blanched, and should be free from blood 
during the operation. Care should be taken not to apply 
the tube or strap too tightly in poorly developed limbs, or 
on parts of the limb where large nerve trunks approach the 
surface, as they may be subjected to an amount of pressure 
which will interfere with their functions subsequently. I 
have knowledge of one case of this nature in which per- 
manent paralysis of the limb followed the use of Esmarch's 
apparatus ; the tube should be applied with just enough 
firmness to control the circulation. 

As the strap, when firmly applied, completely cuts off the 
circulation of parts below, it should be applied for as short 
a time as possible, as gangrene has resulted from its pro- 
longed use. 



CONTROL OF ARTERIAL HEMORRHAGE. 249 

After the removal of the tube there is generally quite 
free- capillary hemorrhage, due to paralysis of vasomotor 
nerves from pressure, but this in a short time stops. This 
apparatus is of the greatest service in controlling hemor- 
rhage at the time of operation, and in amputations and re- 
moval of vascular tumors from the limbs will be found most 
satisfactory. In operations upon bone, either osteotomy or 
sequestrotomy, it is especially useful, as it allows the surgeon 
to have a view of the parts unobscured by hemorrhage. I 
have found its use most satisfactory in operations for the 
removal of foreign bodies, such as needles imbedded in the 
hands or feet or extremities. 

Permanent Control of Arterial Hemorrhage. 

To secure this end the surgeon may resort to the use of 
position, cold, heat, styptics, pressure, cauterization, liga- 
tion, torsion, or acupressure. 

Position. 

In arterial hemorrhage from wounds of the extremities 
elevation of the part will be found to materially diminish 
the amount of hemorrhage ; in hemorrhage from wounds of 
the arteries of the hand, forearm, foot, or leg, forcible flexion 
of the forearm on the arm or of the leg on the thigh will 
be found useful in diminishing the force of the blood- 
current. 

Cold. 

The application of cold by means of a stream of cold 
water or an ice-bag or pieces of ice will often be found an effi- 
cient means of controlling hemorrhage from vessels of small 
calibre ; it is especially applicable to hemorrhage from 
wounds of the vessels of the mouth, nostrils, vagina, or 
rectum. 

Hot Water. 

Hot water will be found a very efficient means of con- 
trolling hemorrhage from small vessels, and it may be used 



250 MINOR SURGERY. 

in the form of a hot antiseptic solution. It is of especial 
value in capillary or parenchymatous hemorrhage and is 
employed in the form of a douche or by means of sponges 
dipped in the hot solution and packed into the wound. 
Injection of hot water is a most satisfactory method of con- 
trolling uterine hemorrhage. 

Styptics. 

These agents are sometimes employed to control capillary 
bleeding or hemorrhage from small vessels, and although 
their use is often satisfactory as regards the control of the 
bleeding, they have the disadvantage of interfering with the 
primary union in wounds, and since the value of asepsis in 
wound treatment has been demonstrated they are now very 
seldom employed. The most valuable styptics which are 
used are alcohol, alum, oil of turpentine, perchloride of iron, 
and persulphate of iron or Monsel's solution, acetic acid, 
and vinegar. 

Pressure. 

For the permanent control of arterial hemorrhage pres- 
sure may be applied directly to the bleeding-point or surface 
by means of a compress of antiseptic gauze or by strips of 
gauze packed firmly into the cavity from whose surface the 
bleeding arises. 

Compresses are used with the best results where the prox- 
imity of a bone gives a firm substance upon which the vessel 
may be compressed, as is the case in the vessels of the scalp. 
Pressure applied by means of packing with strips of gauze 
will be found most efficient in controlling hemorrhage from, 
cavities such as the nose, vagina, or rectum, and in the 
cavities resulting from the removal of necrosed or carious 
bone. Pressure may be indirectly applied by flexing the 
proximal joint over a compress or by firm bandaging of the 
limb. 

In controlling bleeding from a divided artery in a bony 
cavity, such as the inferior dental, a piece of catgut liga- 
ture may be forced into the canal, and will control the 
bleeding in a most satisfactory manner. 



CONTROL OF ARTERIAL HEMORRHAGE. 251 



The troublesome hemorrhages some- 
times occurring after the removal of 
a tooth may be controlled by packing 
the alveolar cavity with a strip of 
gauze, or by introducing a wedge- 
shaped piece of cork and holding it 
in place by fastening the jaws to- 
gether by means of a bandage. 

Cauterization. 

The use of cauterization by means 
of a hot iron is a satisfactory method of 
arresting hemorrhage. Care should 
be taken to have the iron only of a 
dull-red or black heat, as the result 
desired is not the destruction of the 
tissues, but the coagulating effect of 
heat upon them. The form of cautery 
iron employed will depend upon the 
position of the vessel. Paquelin's cau- 
tery is also a satisfactory apparatus to 
use for the control of hemorrhage. 

Control of arterial bleeding by cau- 
terization is often resorted to in opera- 
tions upon the jaws and in the removal 
of tumors from the mouth or pharynx 
or of the tonsils ; it is also frequently 
employed to control hemorrhage in 
operations upon the uterus and the 
rectum, and also that resulting from 
the removal of abdominal tumors, 
where the application of a ligature is 
difficult and often impossible. 

Torsion. 

This method of controlling arterial 
hemorrhage consists in seizing the end 
of the artery, drawing it slightly out 



Fio. 187. 



o o 



Hewson's torsion 
forceps. 



252 MINOR SURGERY. 

of its sheath and twisting it ; it may be accomplished with 
a single pair of forceps or by two pairs of forceps. In the 
latter method the vessel is held by one pair of forceps and 
is twisted by the second pair. 

Torsion of arteries in accidental wounds is quite com- 
mon, and in many cases controls the hemorrhage until 
surgical aid is rendered. I have seen the femoral artery in 
Scarpa's triangle completely controlled in this manner in 
the case of an avulsion of the thigh from railway injury. 

In vessels of moderate size it may be practised with one 
pair of forceps, and the ordinary double-spring artery forceps 
(Fig. 188) will be found satisfactory for such cases. In 
larger arteries two forceps should be employed, or some of 
the numerous forms of torsion forceps which have been de- 
vised for this purpose. (Fig. 187.) 

Fig. 188. 




Double-spring artery forceps. 



Ligation. 



The use of the ligature is by far the most generally em- 
ployed method of controlling arterial hemorrhage. The 
materials used for ligature are silk, hemp thread, catgut, horse- 
hair, iron or silver wire. Catgut or silk is the material gen- 
erally employed. The vessel is seized with a pair of artery 
forceps or a tenaculum (Fig. 189) and drawn out of its sheath, 



Fig. 1 




Tenaculum. 



and a ligature of prepared catgut is thrown around it and 
secured by a surgeon's knot, or by a reef knot and surgeon's 
knot combined, and when firmly tied the ends are cut short 



CONTROL OF ARTERIAL HEMORRHAGE. 253 

in the wound. Silk ligatures which have been rendered 
aseptic are applied in the same manner and the ends may- 
be cut short in the wound. 

When ligatures are applied to vessels in their continuity 
they may be threaded into an eyed probe or aneurism 
needle (Fig. 190) and carried around the vessel and secured. 



Fig. 190. 




Aneurism needle 



A convenient method of applying a ligature to a bleeding- 
point in a deep wound or to a vessel in tissues which are of 
such a nature as not to permit of the isolation of the vessel, 
is to use a curved needle threaded with a catgut ligature, 

Fig. 191. 




Artery occluded by suture. (Esmarch.) 



which is passed deeply into the tissues near the vessel and 
brought out on the opposite side ; the ligature thus placed is 
then firmlv tied, and the ends are cut short in the wound. 
(Fig. 191.) 



254 



MINOR SURGERY, 



Acupressure. 

In this method of controlling arterial hemorrhage a needle 
or pin is used which is thrust through the tissues in such a 
way as to compress the artery. There are a number of 
methods of using the needle or pin and a few of these will 
be described. 

First Method of Acupressure. 

In this method the surgeon places a finger of his left 
hand upon the mouth of the bleeding vessel and with his 
right hand introduces the needle from the cutaneous surface 
and passes it through the thickness of the flap till its point 
projects for a couple of lines or so from the surface of the 



Fig. 192. 



Fig. 193. 




Acupressure — first method ; raw 
surface. (Erichsen.) 



Acupressure — first method ; cutaneous 
surface. (Ekichsen.) 



wound a little to the right side of the tube of the vessel. 
By forcibly inclining the head of the needle toward his 
right he brings the projecting portion of its point firmly 
down on the site of the vessel, and after seeing that it oc- 
cludes the artery he makes it reenter the flesh as near as 
possible to the left side of the wound and pushes the needle 
through the flesh till its point comes out again at the 
cutaneous surface. (Figs. 192 and 193) 

Second Method of Acupressure. 

A straight needle threaded with a short piece of iron or 
silver wire, for the purpose of afterward retracting and 



CONTROL OF ARTERIAL HEMORRHAGE. 255 

removing it, is passed down through the soft parts a little to 
one side of the vessel ; its point is then raised up and passed 
over the artery and is then turned down again and thrust 
into the soft tissues on the other side of the vessel. (Fig. 194.) 

Third Method of Acupressure. 

In this method the point of the needle is passed into the 
tissues a few lines to one side of the vessel, then passed 
under it and afterward pushed on, so that the point again 
emerges a few lines beyond the vessel. A loop of wire is 
next passed over the point of the needle and then after 

Fig. 195. 





: ! : 

Acupressure — second method. Acupressure— third method. 

(Erichsen.) (Erichsex.) 

being carried over the vessel and passed around the oppo- 
site end of the needle it is drawn sufficiently tight to close 
the vessel, and the ends of the wire are secured by making 
a twist around the stem of the needle. (Fig. 195.) 

Fourth Method of Acupressure. 

This method is identical with the third, except that a long 
pin is used in place of the needle, the head of the pin 
remaining outside the wound. 

Fifth Method of Acupressure. 

This method consists in passing a pin or needle through 
the soft tissues close to the artery, and by giving the pin 
a quarter or half rotation twisting the vessel upon itself, 



256 



MINOR SURGERY 



fixing the pin by thrusting its point deeply into the tissues 
beyond. (Fig. 196.) 

Fig. 196. 




Acupressure — fifth method. (Ertchsrn.) 

Sixth Method of Acupressure. 

This method consists in applying the pin as in the fourth 
method, but differs from it in crossing the ends of the wire 
behind the pin so as to embrace the mouth of the vessel 
between them. 



Seventh Method of Acwpr 



essure. 



This method consists in passing a long needle or pin 
through the cutaneous surface deeply into the soft parts at 
some distance from the vessel, making it emerge near the 
vessel, bridging over the vessel and then thrusting it down 
into the soft parts on the other side of the vessel and making 
its point emerge again from the integument. 

Treatment of Venous Hemorrhage. 



Bleeding from small veins often stops spontaneously 
unless there is some pressure upon the wounded veins upon 
the cardiac side of the wound. It is, however, very satis- 
factorily controlled by position or by the application of a 
compress and bandage, or by the use of a ligature ; if the 
divided vein be a large one it is well to secure both ends of 
the vein by ligatures. The free bleeding arising from rup- 
tured varicose veins of the leg is easily controlled by the 
application of a compress and bandage, while hemorrhage 



TREATMENT OF SECONDARY HEMORRHAGE. 257 

from the larger veins, such as the jugular, should be con- 
trolled by the application of ligatures as in the case of 
wounded arteries. The application of the lateral ligature 
to small wounds of veins of large size, such as the femoral, 
has been recommended, and it consists in pinching up the 
wall of the vein so as to include the orifice of the wound 
and throwing a delicate ligature around it. 

The use of the actual cautery may also be required for 
the control of venous hemorrhage in positions in which its 
arrest by pressure or the ligature is not feasible. 

Treatment of Capillary Hemorrhage. 

Capillary or parenchymatous hemorrhage is usually arrested 
spontaneously by the exposure of the injured surface of the 
wound to the air, but it is often so profuse that its arrest 
becomes a matter of importance. To control this form of 
bleeding, pressure may be applied to the bleeding surface 
for a short time, and if this fails to arrest it, sponging 
the surface with dilute alcohol will sometimes prove satis- 
factory ; but the best application to arrest hemorrhage of this 
nature is hot water, which may be used in the form of a 
hot bichloride solution. Acetic acid and vinegar are also 
sometimes employed for the same purpose. In cases where 
the means mentioned above fail to control the bleeding, it 
may be necessary to pack the wound with strips of antiseptic 
gauze ; this dressing is most serviceable when the hemor- 
rhage comes from cavities such as result from the removal 
of tumors or excisions of joints, and for the control of bleed- 
ing following the removal of necrosed or carious bone, pack- 
ing the cavity resulting is the method very generally em- 
ployed. To control hemorrhage from the mucous cavities, 
such as the nose, rectum and vagina, this method of treat- 
ment is frequently resorted to. 

Treatment of Secondary Hemorrhage. 

Secondary hemorrhage following the use of the ligature 
or other means of controlling bleeding is, since the adop- 



258 MINOR SURGERY. 

tion of the antiseptic method of wound-treatment, a much 
less frequent complication of wounds. The treatment of 
this complication is both constitutional and local ; the consti- 
tutional treatment consists in the use of those remedies 
which were mentioned as serviceable in primary hemor- 
rhage, and the drugs upon which the most reliance is to be 
placed are opium and ergot. 

The local treatment of this form of hemorrhage consists 
in the use of the various means of controlling hemorrhage 
which have been mentioned before, such as the ligature, hot 
water, pressure, or the actual cautery. If possible, it is well 
to secure the vessel from which the bleeding arises in the 
wound; if for any reason this cannot be done, the main 
artery should be ligated above the wound if the hemorrhage 
be arterial. 

Rules for Ligating Wounded Arteries. 

The following rules for the application of ligatures to 
wounded arteries are laid down by Ashhurst : 

1. In cases of primary hemorrhage, no operation should 
be performed upon an artery, unless it is at the moment 
actually bleeding. The exception to this rule is in the 
cases where the vessel is seen to pulsate in the wound or 
where the wound involves the region of a large artery and 
the patient has to be transported or may be in a position 
not to receive surgical aid subsequently if needed ; under 
these circumstances, the vessel should be tied or the w r ound 
should be explored to ascertain the fact that no important 
vessel has been injured. 

2. In applying a ligature to a wounded artery, the sur- 
geon should cut down directly upon it at the point from 
which it bleeds and secure it in the wound. 

This rule holds good for both primary and secondary 
hemorrhage. 

3. Two ligatures should be applied, one to each end of 
the artery if it be completely divided, and one on each side 
of the wound if the latter has not completely severed the 
coats of the artery. This procedure is adopted for the 



CONTROL OF HEMORRHAGES. 259 

reason that the arterial anastomosis is so free that the 
proximal ligature will not always, even temporarily, arrest 
the bleeding ; and if it does accomplish this object at the 
time, after the collateral circulation is established, bleeding 
is apt to occur from the distal extremity of the divided 
vessel. If the coats of the artery are not completely sev- 
ered their division should be completed, either before or 
after the application of the proximal and distal ligatures, 
thereby favoring the contraction and retraction of the ends 
of the divided vessel. 

Control of Hemorrhage from Special Parts. 

Epistaxis or hemorrhage from the nose may be so pro- 
fuse as to require surgical interference. To control this 
form of hemorrhage the application of iced compresses to 
the surface of the nose may first be made use of, and if 
this fails to control the bleeding, the surgeon or the patient 
should grasp the cartilaginous portion of the nose with his 
thumb and forefinger in such a manner as to keep the nos- 
trils tightly closed, which will prevent the passage of air 
through the nose and thus permit clots to form, arresting 
the flow of blood. If these simple means fail to arrest the 
bleeding the nasal cavity or cavities may be packed with 
strips of antiseptic gauze introduced into the anterior nares, 
and pushed backward by a director or probe ; this will often 
be found a perfectly satisfactory means of arresting the 
bleeding. This method may be supplemented by a plug of 
antiseptic cotton introduced into the posterior nares with 
the fingers. The use of a rubber tampon, consisting of a 
rubber bag introduced into the nares in an empty state and 
afterward inflated, has also been recommended for the con- 
trol of this variety of hemorrhage. 

Another method of controlling hemorrhage from the nose 
consists in introducing a small piece of sponge, tied to a 
strong silk ligature, into the anterior nares and pushing it 
back along the floor of the nose to the posterior nares ; a 
small piece of sponge about the size of a marble with a 



260 



MINOR SURGERY. 



hole in the centre is threaded on the ligature and pushed 
back until it conies in contact with the first piece of sponge 
introduced, and thus by introducing a number of pieces of 
sponge in this way the nasal cavity may be completely 
filled up and the bleeding is arrested. Care should be taken 
to see that the sponge has been rendered aseptic before 
being introduced, and the nasal cavitv should also be 
washed out with an antiseptic solution before its introduc- 
tion. The sponges may be allowed to remain in place for 
twenty-four to forty-eight hours. (Fig. 197.) 

Fig. 197. 




Plugging the nares from the front. (Roberts.) 



Plugging the nares by means of Bellocq's canula is also 
employed to arrest hemorrhage from the nasal cavities ; the 
canula, armed with a strong ligature, is passed along the 
floor of the nose until it reaches the pharynx, when the 
spring being protruded, the ligature is seized and brought 



CONTROL OF HEMORRHAGES. 



261 



out of the mouth and secured to a plug of lint or antiseptic 
gauze of the required size, and upon withdrawing the in- 
strument the plug is brought into position in the posterior 
Dares and the end of the ligature is allowed to protrude 
from the mouth to facilitate its removal. (Fig. 198.) An 



Fig. 198. 




Plugging the nares with Belloeq's canula. (Fergussok.) 

ordinary flexible catheter may be employed in place of 
Belloeq's canula for the introduction of the ligature. 

Hemorrhage from the Urethra. 

In hemorrhage from the urethra, if profuse, the blood 
will trickle from the meatus, or if efforts at micturition are 
made the first gush of urine will contain blood, but after- 
ward will be clear, and the last urine will contain a few 
drops of pure blood. 

This variety of bleeding, if it proceeds from the anterior 
portion of the urethra, may be controlled by the introduc- 
tion of a catheter and the application of a bandage around 
the penis, carefully applied so as to make only moderate 
pressure. 

12* 



262 MINOR SURGERY. 

If the bleeding comes from the posterior portion of the 
urethra, it will often be controlled by the application of 
cold or pressure to the perineum, or by the introduction of 
a cold steel bougie, or by the injection of a solution of 
tannic acid. 

Hemorrhage from the Bladder. 

In this variety of hemorrhage the first portion of the 
urine may be blood-stained and the last portion will contain 
more blood and clots as the organ contracts, which distin- 
guishes it from hemorrhage from the kidneys, in which the 
admixture of blood with the urine renders it of a smoky 
color or dark-red if the bleeding is profuse. 

To control bleeding from the bladder a catheter should 
be introduced and the urine and clots withdrawn ; the 
bladder should next be washed out with a warm or cold 
boric acid solution, or in severe cases weak astringent solu- 
tions, such as tannic acid or alum, may be employed. The 
application of ice to the perineum and supra-pubic regions 
may also be employed with advantage. 

Hemorrhage from the Rectum. 

This variety of bleeding may be controlled by the injec- 
tion of cold or astringent enemata. If the bleeding be 
profuse a speculum should be introduced, and when the source 
of the bleeding has been discovered the actual cautery or a 
ligature should be applied. If this is not feasible the rectum 
may be plugged with strips of antiseptic gauze, or a piece 
of a rubber catheter of large calibre may be wrapped with 
gauze and introduced into the rectum, the end of the catheter 
being allowed to protrude ; by using this tube flatus can 
escape, and if the bleeding is not controlled blood will 
escape through the tube, preventing the risk of concealed 
hemorrhage. If the bleeding arises from hemorrhoids or 
polypus of the rectum, the operative treatment of these con- 
ditions should be undertaken to permanently control the 
bleeding. 



OPENING AND DRESSING OF ABSCESSES. 263 



Opening and Dressing- of Abscesses. 

Aaite abscesses, as a rule, should be opened by incision, 
and this is best done with a straight, narrow, sharp-pointed 
bistoury ; the incision should be deep enough to freely ex- 
pose the cavity of the abscess, and should be so planned as 
to be parallel with and not across important structures, and 
it should also be made at as dependent a portion as possible. 
Abscesses of the limbs are opened by a longitudinal incision, 
and those in the region of the anus and breast by an in- 
cision radiating from the anus or nipple. 

In deep-seated abscesses in the region of important 
structures the method of opening suggested by Mr. Hilton 
may be employed with advantage ; it consists in making a 
small incision through the skin and cellular tissue ; a director 
is next pushed through the tissues into the abscess cavity, 
which will be shown to have been reached by the escape of 
a little pus along the director ; a dressing forceps with the 
blades closed is now pushed along the director into the 
abscess cavity, and when this has been accomplished the 
director is withdrawn and the forceps are removed with the 
blades expanded so as to dilate the wound and allow the 
pus to escape. 

The cavity of the abscess being emptied of pus, it should 
be irrigated with a stream of carbolic acid solution 1 : 40, 
or bichloride solution, and if the cavity is not very large or 
deep no drainage-tube need be introduced, and a small piece 
of protective may be placed between the lips of the wound 
to prevent their adhesion ; but if, on the other hand, the 
cavity is extensive and deeply situated, a rubber drainage- 
tube should be introduced to the bottom of the cavity to 
secure free drainage and fixed at the surface of the skin by 
a safety-pin. A piece of protective which has been dipped 
in bichloride solution is next placed over the wound, and 
over this is laid a gauze dressing, consisting of a number of 
layers, which has been moistened in carbolic or bichloride 
solution ; this is covered by a number of layers of dry gauze 
which is in turn covered by a piece of rubber tissue, and 



264 MINOR SURGERY. 

over this is placed a few layers of bichloride cotton and the 
dressing is finally secured by a roller bandage. The dress- 
ing is removed at the end of two or three days, the cavity 
being washed out with one of the antiseptic solutions pre- 
viously mentioned ; the drainage-tube may be shortened or 
removed and the dressings are reapplied as at the primary 
dressing. Under this method of treatment acute abscesses 
usually heal more promptly and with less suppuration than 
under the older methods of treatment in which poultices 
were applied. 

Chronic or cold abscesses, which occur chiefly in connec- 
tion with diseases of the bones or joints or of the lymphatic 
system, and are generally tubercular in their origin, may be 
opened in various ways, the time at which this should be 
done depending upon the size and situation of the abscesses 
and the amount of constitutional disturbance which the 
patients experience from their presence. 

A cold abscess may be evacuated by means of the aspi- 
rator ; the pus being withdrawn as far as possible, the punc- 
ture is sealed with a small piece of gauze covered with 
iodoform collodion. Reaccumulation of the pus often takes 
place and the aspiration has to be repeated a number of 
times. The greatest difficulty in the successful removal of 
the contents of cold abscesses by means of aspiration is the 
presence of masses of lymph in the pus which occlude the 
canula and often prevent the complete emptying of the 
cavity. 

These abscesses may also be evacuated by making a punc- 
ture through the skin and overlying tissues with a narrow 
bistoury, the surface having been previously thoroughly 
washed with soap and water and with a carbolic or bi- 
chloride solution ; a director is next pushed through this 
small wound into the cavity of the abscess and the pus is 
allowed to escape by stretching the wound by the director ; 
when the cavity is emptied of pus it is washed out with a 
carbolic or bichloride solution introduced into it by pushing 
the nozzle of a syringe into the cavity, and this is allowed 
to escape in the same way as the pus previously did, and 
when the irrigating solution has all escaped the cavity may 



OPENING AND DRESSING OF ABSCESSES. 265 

be injected with an emulsion composed of iodoform one 
part, glycerin ten parts ; after this has been introduced 
the small wound is closed by a compress of antiseptic gauze 
held in place by a compress of bichloride cotton and a 
bandage or by strips of adhesive plaster. The injection of 
the iodoform emulsion need not be repeated as long as iodo- 
form continues to be excreted with the urine. Cold abscesses 
are also treated by making a free incision into the abscess 
cavity with full antiseptic precautions, and after the escape 
of the purulent matter the walls of the abscess should be 
thoroughly scraped with a curette, and after the cavity has been 
freely washed out with a carbolic or bichloride solution large 
drainage-tubes are introduced and an antiseptic dressing is 
applied to the wound. The dressings are removed as soon 
as they become soaked and the drainage-tubes are shortened 
or removed as the discharge diminishes and the cavity con- 
tracts. 

In evacuating chronic abscesses by means of the aspirator 
or by a small puncture, there is absence of shock and the 
loss of blood is insignificant, so that these procedures should 
generally be first employed, and the more radical operation 
of incision and curetting of the cavity of the abscess, which 
is accompanied with a certain amount of shock and hemor- 
rhage, should be reserved for those cases in which the less 
severe operations have failed to be followed by a satisfactory 
result. 

Diffused suppuration is treated by numerous punctures 
or incisions, which allow the purulent matter to escape, and 
where sloughs are present free incisions may be required to 
give exit to the necrosed tissues ; the introduction of drain- 
age-tubes may also be required. The wounds and the 
cavities, as far as possible, should be washed out with a 
carbolic or bichloride solution and an antiseptic gauze dress- 
ing should be applied. 

Sinuses resulting from abscesses, if superficial, should be 
laid open freely and their surfaces should be scraped with a 
curette and they should then be lightly packed with strips 
of bichloride or iodoform gauze and should be covered by 
an antiseptic dressing. If they are too deep to be treated 



266 MINOR SURGERY, 

by incision their healing may be facilitated by the injection 
of stimulating solutions introduced by means of a syringe ; 
the employment of solutions of chloride of zinc, nitrate of 
silver, and sulphate of copper varying in strength from five 
to twenty grains to the ounce of water will often prove 
satisfactory. 

Dressing of Wounds. 

Incised wounds present the conditions favorable for 
prompt healing and they should first be carefully irrigated 
with an antiseptic solution to remove any blood-clots or 
foreign bodies, and after any hemorrhage which is present is 
controlled by the use of ligatures, if the wound be an exten- 
sive or deep one, provision should be made for drainage by 
introducing a drainage-tube or a few strands of prepared 
catgut to the bottom of the wound, allowing the extremity 
to project from the most dependent portion of the wound. 
In superficial incised wounds, after the hemorrhage has 
been controlled, it is not usually found necessary to make 
any provision for drainage. If the wound be a deep one, 
involving the muscles and deep fascia, buried sutures of cat- 
gut should be applied to approximate the muscles and fascia, 
and if important nerves or tendons have been divided their 
ends should be brought into apposition by sutures of catgut 
or sterilized silk ; the superficial portions of the wound 
should next be brought together by the introduction of a 
number of interrupted sutures, catgut, silkworm-gut, silver 
wire or silk being employed for this purpose ; the accurate 
apposition of the edges of wounds of this variety is secured 
by the introduction of a number of sutures placed closely 
together. 

After a wound of this variety has been closed the subse- 
quent dressing is accomplished by dusting the surface of 
the wound with iodoform or aristol, and a piece of protective 
a little larger than the wound, which has been dipped in a 
1 : 40 carbolic solution, is placed over it ; over this is placed 
a pad of antiseptic gauze, composed of ten or twelve layers, 
which has been soaked in a 1 : 40 carbolic solution or a 



DRESSING OF WOUNDS. 267 

1 : 2000 bichloride solution, and over this is laid a pad of 
dry antiseptic gauze of the same thickness, overlapping the 
wet gauze by a few inches in all directions ; a few layers of 
bichloride cotton are next applied over the gauze dressings 
and the whole dressing is secured in position by the appli- 
cation of an antiseptic gauze bandage. Under this form of 
dressing prompt healing of incised wounds is the rule, and 
the wound need not be re-dressed for a week or ten days 
unless some indications exist for the change of dressing at an 
earlier period. At the time of the first dressing the catgut 
drain or the drainage-tube is usually removed and if the 
adhesion of the edges of the wound is firm the sutures may 
also be removed. An antiseptic dressing is usually next 
applied and allowed to remain in position for a few days 
longer. 

Lacerated wounds present edges which are torn and not 
sharply cut, and the vitality of the injured parts is often so 
seriously impaired that prompt union in this variety of 
wounds is not, as a rule, to be looked for. Wounds of this 
nature should first be irrigated with an antiseptic solution, 
as in the case of incised wounds, and blood-clots and foreign 
bodies should be removed. If the wounds be deep, drain- 
age-tubes should be introduced ; on the other hand if they 
be superficial or if the edges are not closely approximated, 
provision for drainage may be omitted. The torn or irregu- 
lar edges of the wound should next be brought into apposi- 
tion at a few points, by the introduction of a few catgut or 
silkworm-gut sutures, applied not very closely together ; and 
if the edges are discolored and their vitality seems mark- 
edly impaired, it is better not to use sutures, but rest satis- 
fied by bringing them as nearly as possible in contact by the 
use of a few strips of isinglass plaster moistened with a 
bichloride solution. If the edges of the wound are so much 
crushed as to have their vitality destroyed, they may be 
trimmed away with scissors until a surface possessing fair 
vitality is secured. The evil results arising from the intro- 
duction of sutures into this variety of wounds with the 
idea of closely approximating their edges are so common, 
that the surgeon who dispenses with the use of sutures en- 



268 MINOR SURGERY. 

tirely errs upon the safe side. The use of many sutures in 
wounds of this nature often causes marked tension in the 
wound, which is frequently followed by impairment of the 
vitality of the injured tissues and sloughing results. 

The wound should next be dressed antiseptically, and if 
it runs a favorable course it need not be re-dressed for a 
week or ten days ; the time required for the repair of a 
w T ound of this nature is longer than that for an incised 
wound, and a larger number of dressings may be required. 

In lacerated wounds of the extremities continuous irriga- 
tion of the wound by a warm bichloride or carbolic solution, 
applied as described (page 144), is often followed by the 
most satisfactory results ; wounds produced by machinery 
and railway accidents, in which the vitality of the tissues 
is much impaired, are particularly favorable cases for this 
method of treatment, and here the same caution should be 
exercised as regards the introduction of sutures. 

Contused Wounds. — This variety of wounds possesses 
many characteristics in common with lacerated wounds; the 
edges are bruised and the injury of the subcutaneous tissue 
is often more extensive than the size of the external wound 
would lead one to suspect. They are dressed in the same 
manner as lacerated wounds, and the same objection here 
exists to the use of sutures as in the latter class of in- 
juries. 

Punctured Wounds. — These wounds are inflicted by 
sharp-pointed instruments, and it often happens that a 
portion of the vulnerating body remains in the wound, as 
is frequently the case in wounds produced by needles ; and 
another complication in this variety of wound is the injury 
of vessels, giving rise to concealed hemorrhage, or of nerves 
resulting in neuritis. Simple punctured wounds should be 
carefully washed with an antiseptic solution and covered by 
an antiseptic gauze dressing, and if no complication exists 
their healing is usually very rapid. 

When, however, a foreign body remains in the wound, as 
it often happens in punctured wounds produced by needles 
and pins, the punctured wound should be converted into an 
incised wound, and the body should be searched for and 



DRESSING OF WOUNDS. 269 

removed if possible, and in doing this in the ease of wounds 
of the extremities the operation is much facilitated by the 
employment of Esmarch's bandage and strap. After the 
removal of the foreign body the wound is treated as an in- 
cised wound, and an antiseptic dressing should be applied. 
"When concealed hemorrhage occurs after a punctured wound, 
the wound should be laid open and the bleeding vessel 
searched for and ligatured if possible, and the wound should 
afterward be dressed as an incised wound. 

Poi*<:>necl Wounds. — These wounds are caused by the 
absorption, by means of a cut or abrasion in the skin, of 
fluids from a dead body in making dissections or post- 
mortem examinations or in operating upon living subjects, 
and often result in serious consequences. Such wounds, 
as soon as possible after their reception, should be care- 
fully washed out with a solution of bichloride of mercury, 
1 : 2000, or a 30-grain solution of chloride of zinc, and 
then dressed with an antiseptic dressing. If. however. 
this precaution is not taken or the wound has escaped 
notice, and in a few hours becomes inflamed and painful, 
and evidences of lymphatic involvement show themselves, 
the wound should be opened and its surface should be 
thoroughly washed out with a 30-grain solution of chloride 
of zinc, and finally with a 1 : 2000 bichloride solution, and 
it should then be dressed with an antiseptic gauze dressing. 
Under this method of dressing the poisoned wound is often 
converted into a healthy one. even after the lymphatic in- 
volvement is well marked, and it usually heals promptly 
without further constitutional disturbance. 

Gunshot Wounds. — These wounds are produced by small 
shot, balls, or fragments of shells, and are of the nature of 
contused and lacerated wounds, and the vulnerating body as 
well as portions of the clothing are often imbedded in the 
tissues. 

In dressing these wounds any foreign bodies, if they can 
be located, should be removed, and in the search for and 
removal of balls from the extremities the application of the 
Esmarch bandage and strap will be found most useful. The 
wound should next be thoroughly washed out with a 1 : 2<)<>Q 



270 MINOR SURGERY. 

bichloride solution, and an antiseptic dressing applied as in 
the case of other contused and lacerated wounds. 

Powder burns resulting from the explosion of powder, in 
addition to the burning and laceration of the tissues, are 
accompanied by the introduction of grains of unburnt powder 
into the skin, which, if not removed, leave permanent points 
of pigmentation. These wounds should first be washed with 
an antiseptic solution, and upon the face, to avoid unsightly 
pigmentation of the skin, care should be taken to pick out 
the small masses of powder with a needle or the sharp point 
of a tenotomy knife. The surface should then be dressed 
with lint spread with an ointment of boric acid or an ointment 
of aristol, consisting of half a drachm or a drachm of aristol 
to an ounce of vaseline, this dressing being covered by a few 
layers of bichloride or borated cotton, held in place by a 
roller bandage. 

Contusions or bruises differ from contused wounds in the 
fact that the skin is not broken, though in spite of this fact 
there may exist very extensive laceration of the subcutaneous 
tissues, accompanied by more or less extravasation of blood 
from the injured vessels. When not severe enough to re- 
quire operative treatment, they should be dressed by apply- 
ing over them several layers of lint saturated with lead-water 
and laudanum, and over this dressing is placed a layer of 
waxed paper or rubber tissue, and the dressing is secured by 
a roller bandage. 

A solution which I find most satisfactory in the dressing 
of contusions is as follows : 

Aramonii chloridi . . ' . . . . . grs. xx. 

T "- T\. 1 aa f3j. 

Alcohons j UJ 

Aquas -. . q. s. ad fgj. 

Several layers of lint saturated with this solution are laid 
over the contused tissues, and are covered with waxed paper, 
oiled silk, or rubber tissue. 

Extensive collections of blood following contusions often 
remain in the tissues for some time, but usually are ab- 
sorbed. If this result does not follow, or an abscess forms, 



BURNS AND SCALDS. 271 

the blood or pus should be removed by aspiration or by 
incision with full antiseptic precautions. 

Burns and Scalds. 

The dressings employed in the treatment of burns and 
scalds are similar, as the injury to the tissues is practically 
the same in both classes of injuries. Superficial burns or 
scalds, in which the effect of the heat has only extended to 
the superficial layer of the skin, may be treated by the ap- 
plication of lint saturated with a solution of carbonate of 
sodium, a drachm to an ounce of water ; this dressing rap- 
idly relieves the pain, and is a satisfactory application in 
this variety of burns and scalds. In cases in which the 
effects of heat have extended to the deeper tissues, the 
affected surface may be dressed with carron oil, which is 
prepared by rubbing together lime-water and linseed oil 
until a thick creamy paste results ; lint is saturated with 
this mixture and laid over the surface of the burn or scald. 
The dressing is a comfortable one to the patient, but soon 
becomes offensive, and for this reason requires frequent re- 
newals. 

The disadvantage met with in the antiseptic method of 
dressing burns and scalds is the fact that the raw surface 
presented offers the most favorable conditions for the absorp- 
tion of the antiseptic substances employed in the dressings, 
and for this reason the use of bichloride of mercury, carbolic 
acid, and iodoform is not to be recommended in burns or 
scalds involving a large extent of surface, on account of the 
toxic symptoms which may result from their employment. 

A recent burn or scald, by reason of the heat employed 
in its production, is practically an aseptic wound, and it may 
be dressed by covering it with boric acid ointment, and 
placing over this a number of layers of borated or salicylated 
cotton, and holding the dressings in position by a roller 
bandage. 

Aristol, as a substitute for iodoform, may be employed in 
the dressing of burns or scalds, being either dusted over the 



272 MINOR SURGERY. 

surface or used in the form of an ointment, and over this 
application should be placed a few layers of borated or 
salicylated cotton. 

When blebs are present upon the surface of the burn or 
scald, they should be opened to allow the serum to escape. 
If suppuration occurs or the tissues become necrosed by 
reason of the severity of the injury, the surface of the burn 
may be washed with a 1 : 60 carbolic solution or 1 : 4000 
bichloride solution and the same dressing should then be 
applied. 

The ulcers resulting from the separation of the dead tis- 
sues should be touched with a solution of nitrate of silver, 
four grains to the ounce of water, and dressed with lint 
spread with ointment of boric acid or aristol. In the dress- 
ing of extensive burns or scalds of the neck, face, and region 
of the joints, the possibility of serious deformity from con- 
traction of the tissues in healing should not be lost sight of, 
and position, splints and bandages, should be employed to 
prevent, as far as possible, this complication. 

Bedsores. 

These sores usually occur over the sacrum or hips in 
patients who are confined to bed for a considerable time, 
as the result of a long-continued pressure, or in those cases 
where the vital powers are depressed by adynamic diseases, 
and are also a frequent and troublesome complication in 
spinal injuries. Their formation may be prevented in many 
cases by the use of air-cushions or of a water mattress, and 
by keeping the parts exposed to pressure scrupulously clean 
and frequently bathing them with stimulating lotions, such 
as alcohol, olive oil and alcohol equal parts, or soap lini- 
ment. The parts should also be protected from pressure 
by the application of adhesive plaster, or, still better, soap 
plaster spread upon chamois. When the bedsore has actu- 
ally formed, and in many cases its formation is very rapid 
and the slough will be found to involve a large surface of 
the skin over the sacrum, and to extend down to the bone, 



SPRAINS. 273 

we have present a very serious complication, and one which 
requires most careful treatment. 

The dressing of a bedsore before the separation of the 
slough consists in relieving the part from pressure by the 
use of an air-cushion placed under the buttocks, and the 
application of a fermenting poultice until the slough has 
separated. When the slough has become detached the ulcer 
remaining should be well washed with a carbolic or bichlo- 
ride solution and the granulations should be touched with a 
5-grain solution of nitrate of silver; and resin cerate, iodo- 
form, aristol, or boric acid ointment, spread upon lint, should 
be applied to the surface of the ulcer, and a piece of soap 
plaster a little larger than the ulcer should be placed over 
this dressing and held in place by broad strips of adhesive 
plaster. This dressing should be renewed every day or 
every other day, and means should be adopted to protect 
the parts from further pressure, and the constitutional con- 
dition of the patient should be improved by the adminis- 
tration of a nutritious diet, tonics, and stimulants. The 
application of the galvanic current has been employed with 
good results to promote the healing of the ulcer in obstinate 
cases. 

Sprains. 

Sprains of joints from twists or other external violence 
resulting in the stretching or laceration of the ligaments are 
injuries which require careful dressing. 

Sprains may be first treated by the application of cold- or 
hot-water dressings for a few hours, or by the application 
of lead-water and laudanum, the joint being kept at rest by 
the use of a splint or by confining the patient in the recum- 
bent posture in the case of sprains of the joints of the lower 
extremities. 

After a few days' use of the lead-water and laudanum 
dressing the swelling usually subsides and the joint may 
be fixed by the application of a moulded soap-plaster splint 
or felt splint held in place by a firmly applied roller band- 
age, which should be worn for a week or ten days; in ordi- 



274 MINOR SURGERY. 

nary cases after this time the splint may be removed and 
the patient should be encouraged to use the joint. In cases 
of severe sprain, on the other hand, the pain and swelling 
persist for some time, and here the fixation of the joint by 
a soap plaster, or better by a plaster- of-Paris bandage, will 
be found useful for a few weeks. If upon the removal of 
this dressing the parts are still painful and swollen, the 
swollen tissues should be painted with tincture of iodine; or 
the method of applying tincture of iodine recommended by 
Mr. Jordan, that is, the application of the iodine in a broad 
band around and not over the swollen tissues, may be em- 
ployed. The joint should next be surrounded by a piece 
of lint spread with an ointment composed of equal parts of 
ointment of mercury and ointment of belladonna, and a 
moulded soap-plaster splint being fitted to the joint, it is 
held in place by a firmly applied bandage. This will be 
found a most satisfactory dressing in the treatment of 
sprains after they have passed their acute stage. The dress- 
ing is removed at intervals of three or four days, the joint 
is sponged off with alcohol, and a similar dressing is reap- 
plied; and this method of dressing may have to be continued 
for some weeks, but the results obtained by its continuous 
use are often most satisfactory. An ointment of icthyol 
one part to lanolin three parts may also be used in the 
same manner as the ointment of belladonna and mercury 
with good results in the treatment of these injuries. The 
employment of pressure in the . treatment of sprains, by 
means of strapping, is also sometimes advantageous. 

In the chronic stage of a sprain, after all dressings have 
been removed, the methodical use of massage is often most 
beneficial ; and after the parts have been thoroughly 
manipulated a flannel bandage should be applied which, by 
its elasticity, gives a certain amount of support to the 
parts. 

Sprain-fracture. — Under this name Mr. Callender has 
described an injury which consists in the separation of a 
ligament or tendon from its point of insertion, with the 
detachment of a thin shell of bone; this injury is apt to 
occur about the ankle-, knee-, elbow-, and wrist-joints, and 



TRACHEOTOMY. 275 

the treatment is the same as that of an ordinary fracture in 
the same locality. This injury is probably much more 
common than is generally supposed in connection with 
sprains of the joints, and is, I think, in many cases the 
cause of the tardy restoration of the function of sprained 
joints, this injury being overlooked and the injury simply 
being treated as a sprain, and the patient being encouraged 
to use the part before the union of the bone has been 
accomplished. 

Strains of muscles arid fascia varying in severity from 
simple stretching of the fibres to absolute rupture are treated 
by putting the parts at rest and by the application of 
pressure by means of adhesive straps or of a bandage : in 
strains of the muscles and fascia of the back the use of 
broad strips of adhesive plaster, applied as in cases of 
fracture of the ribs, will be found most satisfactory, and in 
the treatment of the later stages of the injury the employ- 
ment of massage will often be followed by good results. 



Tracheotomy. 

This operation consists in dividing the tissues over the 
trachea in the median line of the neck, and after the trachea 
has been exposed it is opened by dividing two or three of 
the tracheal rings. 

The operation of tracheotomy may be required to relieve 
the dyspnoea dependent upon membranous or diphtheritic 
laryngitis, growths in the larynx or trachea, growths ex- 
ternal to these organs causing pressure upon them, oedema 
of the mucous membrane of the larynx or trachea from 
inflammation from burns or scalds, or from the inhalation 
of irritating gases or the swallowing of corrosive liquids. 
The operation may also be required for the removal of 
foreign bodies from the larynx, trachea, or from the bronchi. 
as well as for the relief of the dyspnoea due to their presence, 
and it is also required in cases of fracture or laceration of 
the larynx or trachea, and occasionally in cases of spasm 
of the glottis, and in cases of glossitis to overcome the 



276 MINOR SURGERY. 

mechanical obstruction which prevents the entrance of air 
into the air-passages. 

The ease with which the operation is performed varies 
much in different cases; it is, as a rule, a much simpler 
operation in adults than in children. In the latter subjects 
the shortness of the neck, the relatively greater size of the 
thyroid gland and the possible presence of the thymus body, 
the great vascularity of the parts, and the abundance of 
adipose tissue, render the trachea difficult to expose and 
open. 

Under certain circumstances the operation may be per- 
formed with very few instruments ; but if the surgeon has 
the choice he will find it convenient to have at hand two 
small scalpels, one short grooved director, a tenaculum, two 
aneurism needles which may be used as retractors, one pair 
of artery forceps, haemostatic forceps, two pairs of dissect- 
ing forceps, a pair of scissors, a sharp-pointed tenotome, a 
pair of tracheal forceps, a tracheal dilator, tracheotomy 
tubes, tapes, ligatures, sponges, a flexible catheter, and 
feathers. The director should be short; the ordinary 
grooved director is too long to use with satisfaction in oper- 
ating upon the short necks of children ; so that I have had 
made a shorter and somewhat broader one, which has a 
bevelled extremity which allows it to be passed with ease 
between the different layers of the tissue. (Fig. 199.) 

Fig. 199. 




Author's tracheotomy director. 

Hcemo static forceps are also of great use in controlling 
hemorrhage during the operation in case of the division of 
vessels which bleed freely, when the operator from the 
urgency of the case does not think it justifiable to ligature 
them at the time of their division. They may also be em- 
ployed under similar circumstances to clamp the isthmus of 



TRACHEOTOMY. 



277 



the thyroid gland on either side of the trachea when it 
becomes necessary to divide it to expose the trachea. 

A sharp-pointed tenotome is the instrument I prefer to 
employ in opening the trachea as its sharp point enables it 
to be easily thrust into the trachea, and its short cutting 
surface and the narrowness of the blade obscure as little as 
possible the line of incision and thus enable the operator to 
see exactly where he is cutting. 

Tracheal dilators of various kinds are employed, but the 
most satisfactory tracheal dilator which I have employed is 
that of Golding-Bird (Fig. 200), which is a self-retaining 
instrument; the blades are slipped through the tracheal 
incision and are then expanded by turning the screw to 
which they are attached. 

Trousseau's tracheal dilator, the blades of which are in- 
troduced through the incision in the trachea and are ex- 
panded by bringing together the handles, is also a satisfactory 
instrument (Fig. 201), but is not as useful as the tracheal 



Fig 200. 



Fig. 201. 





Golding-Bird's tracheal dilator. 



Trousseau's tracheal dilator. 



dilator previously mentioned, as it has to be retained in 
position by the hand. Tracheal dilators may be improvised 
from bent hairpins or pieces of wire, which will often serve 
a useful purpose where ordinary dilators cannot be obtained. 

It is also well to have at hand a number of pliable 
feathers to be used in cleaning the trachea or larynx of 
mucus or membrane after it has been opened, and by their 
use this object can be accomplished with little risk of injury 
to the mucous membrane. 

Tracheal forceps, which are constructed with a double 

13 



278 



MINOR SURGERY. 



spring and curved blades are also useful in removing mem- 
brane or foreign bodies from the larynx above the wound or 
from the trachea below the tracheal incision. (Fig. 202.) 



Fig. 202. 




Tracheal forceps. 

Tracheotomy -tubes of various shapes are made of silver, 
aluminium, hard and soft rubber, but the tube which I think 
is the most satisfactory for general use is a silver quarter- 
circle tube with a movable collar (Fig. 203), and provided with 
a fenestrated guide. (Fig. 204.) A good tracheotomy-tube is 



Fig. 203. 



Fig. 204. 




Silver tracheotomy-tube. 




silver tracheotomy-tube with 
fenestrated guide. 



one which inflicts the least possible injury upon the mucous 
membrane of the trachea, and to insure this object the part 
of the tube within the trachea should lie exactly in its axis 
and its free extremity should be capable of as little move- 



OPERATION OF TRACHEOTOMY. 279 

ment as possible. The tracheotomy-tube is held in position 
after being introduced by means of tapes attached to the 
shield of the tube and tied around the neck. 

Position of Patient for Tracheotomy. 

The best position in which to place the patient for this 
operation is that which brings the neck into the greatest 
prominence, and this can best be obtained by laying the 
patient upon his back upon a firm table and placing under 
the shoulders a round cushion ; or an empty wine-bottle, or 
a roller-pin wrapped in towels will answer the same pur- 
pose. If an anaesthetic is not used the arms should be held 
by an assistant, which is better than securing them by a 
binder fastened around the chest, which restricts respiratory 
movements. 

Use of an Anaesthetic in Tracheotomy. 

As a rule, I think it is better not to administer an anaes- 
thetic in performing this operation, as little pain is experi- 
enced, in cases in which the dyspnoea is well marked, after 
the incision in the skin has been made, and I have seen the 
dyspnoea which was well marked before the use of the anaes- 
thetic suddenly become so alarming that the trachea had to 
be opened before it was thoroughly exposed, which is a pro- 
cedure always attended with risk. So strong is my con- 
viction that the risks of the operation are much increased 
by the employment of an anaesthetic that in later years I 
have abandoned its use. 

Operation of Tracheotomy. 

The trachea may be opened above the isthmus of the thy- 
roid gland or below it, and these operations constitute 
respectively the high and low operations. 

The high operation is generally selected, because at this 
point the trachea is more superficial and is more easily 
exposed, whereas in the low operation the trachea is more 
difficult to expose by reason of its relatively greater depth, 



280 MINOR SURGERY. 

the large size and number of the veins, and its proximity to 
the large arterial trunks. 

The patient being placed in position, the operator stands 
at the head of the patient ; this position I prefer, as it is 
easier from this point to keep the incisions exactly in the 
median line of the neck. The operator next makes himself 
familiar with the landmarks of the neck ; locating the position 
of the cricoid cartilage, he makes an incision through the 
skin in the median line of the neck from one and a half to two 
inches in length, the position of the cricoid cartilage being 
the middle point. There is no disadvantage in making a 
longer incision if a freer exposure of the parts is required. 
Having divided the skin, the operator will often see a large 
vein lying in the superficial fascia — the superficial anterior 
jugular ; this should be displaced, and the fascia divided 
upon the director. 

The surgeon should keep his incisions strictly in the 
median line of the neck, for this is the line of safety ; and he 
should be careful, as the wound increases in depth, not to 
make the incisions too short, so that it becomes funnel- 
shaped. 

When the deep fascia is exposed it should be picked up 
and divided upon the director, and any large veins in the 
line of the wound should be carefully displaced, or, if this is 
impossible, they should be ligatured on each side and then 
divided between the ligatures. 

The operator now looks for the intermuscular space 
between the sterno-hyoid and the ster no-thyroid muscles, 
which can generally be found without difficulty, and the 
muscles are now separated in this line with the handle of the 
knife or with the director, and the isthmus of the thyroid 
gland will be exposed. The muscles should now be held 
aside by retractors placed on either side. A caution here as 
to the use of retractors may not be out of place : the operator 
should place them himself and allow the assistants to hold 
them. I once almost lost a case in which I had the trachea 
exposed, and while I turned aside to pick up a knife with 
which to open it, my assistant, in replacing a retractor which 
had slipped, included the movable trachea in the grasp of the 



OPERATION OF TRACHEOTOMY. 281 

retractor, pulling it to one side and completely shutting off 
respiration ; when I attempted to find the trachea to open 
it I could only feel the anterior surface of the vertebrae at 
the bottom of the wound, and it was only when I appreciated 
what had occurred, and lifted the retractor, allowing the 
trachea to spring back into its normal position, that I was 
able to open it. Mr. Durham and Mr. Marsh mention 
somewhat similar cases in which the trachea and vessels were 
held aside with retractors by assistants until the surgeon had 
exposed the cervical vertebrae. 

The operator should carefully explore the wound with the 
finger, to locate exactly the position of the trachea, and to 
ascertain, if possible, the presence of any anomalous arteries. 

The isthmus of the thyroid gland is exposed, which 
generally occupies a position over the first three tracheal 
rings ; this is usually surrounded by a plexus of veins which 
should be displaced with the director, or, if this is impos- 
sible, they should be ligatured on each side and divided 
between the ligatures. The thyroid isthmus is next dis- 
placed upward or downward, according as the surgeon 
desires to open the trachea below or above this body. This 
is often done without difficulty, especially its upward dis- 
placement; but when there is difficulty in displacing it 
downward, a procedure recommended by Bose may be em- 
ployed, which consists in making a transverse incision across 
the cricoid cartilage to divide the layer of fascia by which the 
isthmus is bound down ; a director is then passed into this 
incision, and the isthmus is gently depressed without diffi- 
culty. 

Having displaced the isthmus of the thyroid gland upward 
or downward, the trachea, yellowish-white in appearance, 
covered by the tracheal fascia, should be exposed ; this fascia 
should next be thoroughly broken up with the director or 
handle of the knife so as to bare the trachea, and in doing 
this the operator can feel it crepitate under the finger from 
the suction of air drawn in with inspiration. Having 
arrived at this stage of the operation the operator should 
examine the wound to see that it is free from hemorrhage 
and he should also replace the retractors so as to expose as 



282 



MINOR SURGERY 



large a portion as possible of the trachea, for, be the case 
ever so urgent, he now feels assured that he can open the 
trachea in a moment if the breathing should cease. The 
trachea is now fixed with a tenaculum introduced into it a 
little to one side of the median line ; an incision is made 
into it with a narrow knife from below upward, from one- 
half to three-fourths of an inch in length (Fig. 205), care 

Fig. 205. 




Opening the trachea. (Liston.) 

being taken to see that this incision is in the median line, 
for if the trachea be opened by a lateral incision the wound 
does not heal so promptly and the tracheotomy-tube does not 
fit well, and its lower extremity may cause injury to the 
mucous membrane of the trachea. If the wound be a deep 
one, after fixing the trachea with the tenaculum the opera- 
tor may lift it slightly from its bed, thereby bringing it more 
prominently into view and making it more superficial in 
the wound, thus facilitating its opening. As soon as the 
incision is made into the trachea there is a gush of air from 
the wound in the trachea mixed with blood or membrane ; this 
should be wiped away with a sponge and a tracheal dilator 
should next be introduced and the trachea should be cleared 
of membrane, if it is present in the region of the wound, 
with a feather or with forceps. The tracheotomy-tube is 



OPERATION OF TRACHEOTOMY. 283 

next introduced and is secured in position by tapes tied 
around the neck. 

If respiration has ceased artificial respiration should be 
resorted to or the use of a tube attached to a bellows, or 
Fell's apparatus, and these efforts should be continued for 
at least fifteen minutes, for I have seen resuscitation take 
place in patients who were apparently dead by a persistent 
employment of artificial respiration. 

The care of the tube is a matter of some importance 
after its introduction ; the inner tube should be removed at 
short intervals, washed and replaced, and if the operation 
has been done for an inflammatory condition of the larynx 
or trachea a moistened feather should occasionally be passed 
through the tube into the trachea to withdraw any mucous 
or membrane which is present. In cases of croup after 
tracheotomy the use of a spray of steam or of a spray com- 
posed of 

Carbonate of soda 3j to o'J ss - 

Glycerin f.^ij- 

"Water ^S v j* 

applied by means of a steam atomizer, the spray being 
directed over the opening of the tube, will be found most 
satisfactory in softening the discharges and thus facilitating 
their expulsion through the tube. 

The tracheotomy-tube is usually allowed to remain in the 
trachea from five to ten days : its permanent removal is in- 
dicated as soon as the patient is able to breathe through the 
larynx with the wound in the trachea closed ; its use may 
be required for a longer time, but as soon as the indication 
for its presence has disappeared the sooner it is removed 
the better, for its presence sometimes sets up a troublesome 
tracheitis. x\fter its removal the wound rapidly diminishes 
in size, the healing taking place by granulation and con- 
traction. Difficulty is occasionally met with in the perma- 
nent removal of tracheotomy-tubes; for the causes and treat- 
ment of this complication the reader is referred to special 
works upon tracheotomy. 

Where the operation of tracheotomy is done for the re- 



284 MINOR SURGERY. 

moval of foreign bodies from the air-passages, the steps of 
the operation are the same, but after the removal of the 
foreign body the treatment of the wound is somewhat dif- 
ferent. If the foreign body has remained in the trachea 
only for a short time the wound in the soft parts may be 
closed by means of sutures or may be allowed to remain 
open, being covered by a piece of moistened gauze, and the 
use of the steam spray is here also beneficial for a few days. 
If, however, the body has remained in the larynx, trachea, 
or one of the bronchi for some time and has set up a certain 
amount of inflammatory trouble, it is better to introduce a 
tracheotomy-tube and allow it to remain for a few days. If 
it is found impossible to locate or remove the foreign body 
at the time of operation, a tracheotomy-tube should be in- 
troduced and allowed to remain until the foreign body is 
expelled through the tube or removed subsequently by 
means of forceps. 

Laryngectomy. 

In this operation an opening is made into the air-passages 
through the crico-thyroid membrane. It is a simple opera- 
tion, and one which is practically free from risk, and can 
therefore be performed much more rapidly and safely in 
urgent cases than tracheotomy. 

In this operation the same objection exists to the use of 
an anaesthetic as in tracheotomy, and therefore it should be 
dispensed with. The patient being placed in the recumbent 
posture, with the shoulders slightly elevated and the head 
thrown back to make the neck as prominent as possible, the 
surgeon feels for the prominence of the thyroid cartilage, 
and steadying the larynx between the finger and thumb of 
the left hand, he makes an incision in the median line over 
the centre of the thyroid cartilage and extending downward 
for an inch or an inch and a half. The skin and superficial 
fascia being divided, the fascia between the sterno-liyoid 
muscles and the areolar tissue is exposed and divided, and 
the crico-thyroid membrane is exposed. The knife is then 
passed transversely through the membrane into the larynx, 



LARYNGOTOMY. 285 

care being taken that both that membrane and the mucous 
membrane which covers its inner surface are divided at the 
same time. As soon as the knife enters the cavity of the 
larynx blood and mucus will be forcibly expelled. 

The wound should be carefully enlarged and a tube intro- 
duced, which differs from the ordinary tracheotomy-tube in 
being slightly flattened ; this is secured in position by tapes 
tied around the neck as in the case of the ordinary tracheal 
tube. The only bleeding which is likely to occur is from 
the crico-thyroid arteries or veins, and if these cannot be 
avoided, and are divided in the operation, they should be 
temporarily secured by haemostatic forceps or ligatured, and 
if the case is not extremely urgent, all bleeding should be 
arrested before the crico-thyroid membrane is incised. 

The after-treatment of cases of laryngotomy is similar to 
that of cases of tracheotomy ; the same attention is required 
in the care of the tube and in the general management of 
the patient. 

Laryngo-tracheotomy. 

This operation consists in making an incision into the 
air-passages by dividing one or two of the upper rings of the 
trachea, the crico-tracheal membrane, the cricoid cartilage, 
and the crico-thyroid membrane. This operation is employed 
in cases where, from the age of the patient, the crico-thyroid 
space is too small to admit of a sufficient opening, or in 
those in which, for any reason, the surgeon does not deem 
it advisable to attempt to open the trachea lower down. The 
incision in the skin and superficial fascia of the neck is made 
in the same manner as in the operation of laryngotomy, but 
is carried a little further downward. It may be necessary 
to displace the isthmus of the thyroid gland downward to 
expose the upper portion of the trachea, and when the 
trachea is exposed the incision should be made through this 
and the cricoid cartilage from below upward. 

This operation is more often performed in the high opera- 
tion of tracheotomy than is generally supposed. A trache- 
otomy-tube is introduced through the wound and secured by 

13* 



286 



MINOR SURGERY. 



tapes tied around the neck, and the care of the tube should 
be similar to that in cases of tracheotomy. 

Intubation of the Larynx. 



This procedure, at the present time, is widely employed 
as a substitute for tracheotomy in the treatment of the 
dyspnoea due to inflammatory affections of the larynx or 
trachea, or stenosis of the larynx ; it consists in the intro- 
duction of a metallic tube into the larynx, which is allowed 
to remain in place for a few days. The operation has been 
recently reintroduced to the profession by Dr. O'Dwyer, of 
New York, who has devised a set of ingenious instruments 
for the purpose of laryngeal intubation. 

Fig. 206. 




Mouth-gag. 



The instruments required are a mouth-gag (Fig. 206), 
with which the jaws are separated and held open ; an in- 
strument for the introduction of the tube, which is fastened 

Fig. 207. 





Intubation-tube and introductor. 



to the obturator which fills the cavity of the tube (Fig. 207), 
and an instrument for extracting the tube after it has been 
placed in the larynx. (Fig. 208.) The tubes are of metal 



INTUBATION OF THE LARYNX 



287 



and have a collar which rests upon the false cords and bulge 
slightly toward their middle and again taper toward their 
lower extremity ; at the collar of the tube there is a perfora- 
tion through which a strand of silk is passed which is made 
into a loop ; this is used to allow the operator to remove the 



Fig. 208. 




Intubation-tube extractor. 



Fig. 209. 




3-4- 



tube if on its introduction it is found to have passed into the 
oesophagus instead of the larynx, and also is used to remove 
the tube if it becomes occluded with mem- 
brane while in the larynx. The intubation 
set now in common use is provided with six 
tubes ranging in size from such as are suited 
for a child of one year or less up to the age 
of twelve or fourteen years. (Fig. 209.) 

In performing the operation of intuba- 
tion of the larynx the child is placed upon 
the lap of the nurse or assistant wrapped 
in a blanket and the arms are secured by 
the nurse holding the elbows so as not to 
interfere with the respiratory movements. 

The patient's head is next secured by an 
assistant, and the position of the head, 
neck and body, should be that as if it hung 
from the top of the head, and this position 
should be firmly maintained during the in- 
sertion of the tube. The mouth-gag is 
next inserted upon the left side and the 
blades dilated so as to open the jaws widely, 
and as the gag is self-retaining this position is easily 
maintained. The jaws being thus held open, the operator, 



Scale of intuba- 
tion-tubes. 



288 MINOR SURGERY. 

sitting on a chair facing the patient, next introduces the 
index finger of the left hand into the mouth and passes it 
over the tongue until he feels the epiglottis ; the introducing 
instrument to which the tube is attached is held in the right 
hand and this is now introduced into the mouth, first seeing 
that the silken loop is free, and it is swept over the tongue 
and passed down until it touches the epiglottis ; this is 
hooked up by the index finger of the left hand and the tube 
is passed into the larynx ; the index finger of the left hand 
is then transferred to the edge of the tube and by drawing 
upon the trigger of the instrument with the index finger of 
the right hand the obturator is detached, and the instrument 
is withdrawn, and before removing the finger it is well to 
place it upon the head of the tube and to sink it well into 
the larynx. As soon as the obturator is removed there is 
usually a violent expiratory effort which is accompanied by 
a gush of mucus, muco-purulent matter or membrane from 
the tube, and after this escapes the breathing is usually satis- 
factorily established. If the operator has passed the tube 
into the oesophagus and has detached it from the introducing 
instrument, and no improvement in the respiration takes 
place, it should be withdrawn by the silk loop and attached 
to the obturator and another attempt should be made to in- 
troduce it into the larynx. 

The mistake which inexperienced operators make in in- 
troducing the tube is in not hugging the posterior surface of 
tongue closely, so that they pass the tube over the epiglottis 
into the oesophagus. 

The silken lopp may be brought out at one side of the 
mouth and fastened around the ear or fastened to the side 
of the face by strips of adhesive plaster for a few hours, so 
that by drawing upon it the nurse or attendant is able to 
withdraw the tube instantly if it should become obstructed 
with membrane ; or, if it is coughed up, by this means it 
may be withdrawn from the oesophagus if it has not been 
expelled from the mouth. Some operators keep the loop 
attached to the tube during the time it is retained in the 
larynx, others prefer to remove it after several hours and 
remove the tube by means of the extracting instrument when 



INTUBATION OF THE LARYNX. 289 

required. The tube is removed at the end of the second or 
third day and if the child is able to breathe comfortably for 
an hour or two it is not reintroduced ; if. however, the dys- 
pnoea returns it is reintroduced and allowed to remain one 
or two days longer ; several attempts may have to be made 
before the tube is permanently removed, but it is usually 
dispensed with from the third to the eighth day. 

The most serious complication which is apt to occur 
during the introduction of the intubation-tube is the de- 
tachment and pushing of a mass of membrane in front of 
the tube into the trachea ; if this is too large to be expelled 
through the tube the breathing is suddenly arrested, and the 
tube should be removed, and if the mass of membrane does 
not escape upon the expiratory efforts of the patient the 
trachea should be rapidly opened as the only means of re- 
establishing the respiratory function. So much do I dread 
this accident, which has occurred in a few cases, that I 
never introduce an intubation-tube without having at hand 
the necessary instruments to do a tracheotomy if it should 
be suddenly required, and if possible obtain the consent of 
the parents or friends to perform tracheotomy if it should 
be indicated. 

One of the greatest troubles after intubation of the larynx 
is the satisfactory feeding of the patient ; liquids as a rule 
are not swallowed well, a portion of them escaping into the 
tube, causing coughing and difficulty in breathing. The 
diet I usually order is of semi-solids, such as corn-starch, 
soft-boiled eggs, and mush ; and if these are not well swal- 
lowed it may be necessary to resort to nutritious enemata 
or the use of a stomach-tube to introduce food. Some 
patients swallow liquids and semi-solids quite w T ell if the 
head is dropped a little lower than the body during the act 
of deglutition. 



PART III. 

FRACTURES 



In the following article the author has endeavored to 
confine himself simply to a description of the varieties of 
fracture and to their dressing and treatment, and he has 
tried as far as possible to avoid the multiplication of dress- 
ings, being satisfied to describe a few of the methods of 
dressing most frequently employed. He has also avoided 
the description of complicated splints and dressings, by the 
use of which in certain fractures most excellent results are 
obtained, but has preferred to recommend the employment 
of simple splints and dressings, which can be obtained by 
physicians practising in districts remote from large cities, 
where the services of an instrument-maker cannot be ob- 
tained to construct special apparatus for the treatment of 
these injuries. 

Varieties of Fractures. 

A complete fracture is one in which the line of separation 
completely traverses the bone, involving the entire thickness 
of the bone. 

An incomplete fracture is one in which there is only«a 
partial separation of the bone-fibres (Fig. 210), under which 
name are included partial or " green- stick" fracture, in 
which some of the bone-fibres have given way, while the 
remaining fibres have been bent by the force and have not 
been broken. (Fig. 211.) Fissured, punctured, indented, 



VARIETIES OF FRACTURE 



291 



and perforating fractures are also included in the class of 
incomplete fractures. (Fig. 212.) 

A simple or closed fracture is a fracture in which there 
are but two fragments, and the seat of injury in the bone does 



Fig. 210. 



Fig. 211. 



Fig. 212. 






Incomplete fractun 
of femur. 



Partial or green-stick 
fracture of radius. 



Fissured fracture of 
humerus. (Gurlt.) 



not communicate with the external air by a wound in the 
soft parts. 

Compound or open fractures are fractures in which the 
seat of injury in the bones communicates with the external 
air by a wound in the soft parts. 

Comminuted fractures are those in which there are more 
than two fragments, the lines of fracture intercommunicating 
with each other. (Fig. 213.) 



292 



FRACTURES. 



A multiple fracture is one in which a bone is the seat of 
two or more distinct fractures at different points, the lines of 
fracture not necessarily communicating with each other. 

Complicated fractures are such as are accompanied by 
some serious injury of the parts in the region of the frac- 
ture — as, for instance, the laceration of important blood- 
vessels or nerves, contusion or laceration of the muscles, or 
dislocation of a neighboring joint. 



Fig. 213. 



Fig. 215. 




Comminuted frac- 
ture of patella. 

Fig. 214. 





Impacted fracture. 



Transverse frac- 
ture of femur. 

(GuRLT.) 



Impacted fractures are those in which one fragment is 
driven into and fixed in the other, the impaction taking 
place at the time of fracture, or being caused by force sub- 
sequently applied. (Fig. 214.) 



DIRECTION OF FRACTURE. 



293 



Direction of Fracture. 

A transverse fracture is one in which the general line of 
division of the bone is at right angles with the long axis of 
the bone. (Fig. 215.) Transverse fractures of the long 
bones are rarely met with, the line of fracture usually being 
more or less oblique. 



Fig. 216. 



Fig. 217 




Oblique fracture of humerus. 
(Stimson.) 



Longitudinal fracture of tibia. 
(Stimson.) 



An oblique fracture is one in which the line of separation 
is oblique to the long axis of the bone. This is one of the 
most common directions of the line of fracture. (Fig. 210.) 

A longitudinal fracture is one in which the line of sepa- 
ration runs in the general direction of the long axis of the 



294 FRACTURES. 

bone. (Fig. 217.) This form of fracture is rare, but is 
sometimes met with in the long bones as the result of gun- 
shot injury. 

Epipthy seal fracture or separation occurs before complete 
ossification has taken place between epiphysis and diaphysis, 
and is rarely seen after the twentieth year of life ; the direc- 
tion of the epiphyseal separation is transverse. (Fig. 218.) 




Epiphyseal fracture of head of humerus. (Moore.) 

The deformity or displacement in fractures is either angu- 
lar, transverse, longitudinal, or rotary. 

Repair of Fractures. 

The process of repair in cases of fracture is concisely 
stated by Ashhurst as follows : " The traumatic irritation 
propagated from the broken bone causes swelling of the 
periosteum, active proliferation, and formation of a sheath 
of new bone around the seat of fracture ; this is the 
ensheathing or ring callus of surgical writers. At the 



EXAMINATION OF CASES OF FRACTURE. 295 

same time, the medulla feels the effect of the irritation, 
becomes hardened, and partially ossified ; this constitutes 
the interior or pin callus. Lastly, the osseous tissue itself 
undergoes cell-proliferation, and union of the fragments 
takes place — mutatis mutandis — precisely by the same pro- 
cess that we have already studied in considering wounds of 
the soft tissues. The new material which is thus developed 
between the fragments themselves, constitutes what Dupuy- 
tren called the intermediate, permanent, or definitive callus, 
in contradistinction to the ensheathing and interior forms 
of callus, which are temporary or provisional." 

Examination of Cases of Fracture. 

In examining a*case of fracture to locate the nature and 
seat of fracture, the clothing should be removed from the 
part with as little disturbance as possible, and it is better, 
in most cases, to cut or rip the clothing, rather than to 
attempt to remove it in the ordinary manner. The surgeon 
should first inspect the injured part, and, where possible, com- 
pare it with its fellow, as in the case of injuries of the extremi- 
ties ; much valuable information is also derived from the 
patient or his friends as to the manner in which the injury 
was produced. The part should next be carefully examined 
by the surgeon ; if it be one of the extremities which is 
injured, it should be gently lifted, firm extension being made 
at the same time, the surgeon by his touch and by gentle 
movements seeking to locate the seat of fracture ; and he 
may, by this manipulation, at the same time develop crepitus. 

All manipulations should be made with care, and with the 
greatest gentleness, not only to save the patient from pain, 
but also to prevent the soft parts in the region of the fracture 
from being injured by the rough or sharp fragments of the 
bone. Rough handling of fractures may increase the mus- 
cular spasm by the irritation caused by the sharp fragments 
of the bones, and may also result in the injury of important 
vessels and nerves, and indeed a simple fracture may be 
converted into a compound one by forcible and injudicious 
manipulations. 



296 FRACTURES. 

The sooner the examination is made after the fracture has 
occurred the better, for at this time there is less swelling in 
the region of the injury, and the surgeon can locate the bony 
prominences with much more ease, and can often discover 
the exact seat of the fracture with the least amount of 
manipulation of the parts. When a case of suspected frac- 
ture is not subjected to examination for several days after 
the reception of the injury, the parts in the region of the 
supposed fracture are often so much swollen that it is impos- 
sible to accurately locate its seat, and in such a case it is often 
necessary to wait until the swelling has subsided before the 
position of the fracture can be satisfactorily fixed, the case 
being treated in the meantime as one of fracture. 

Ancestheties may be employed to relieve the patient from 
pain and to obliterate muscular spasm in the examination of 
fractures, and their employment is often of the greatest 
service in the diagnosis of obscure or complicated fractures, 
especially those in the neighborhood of joints ; but the sur- 
geon should remember that all manipulations should be made 
with the same gentleness as when the examination is con- 
ducted without anaesthesia, for there is the same risk of injury 
to the surrounding structures by the fragments ; this pre- 
caution is often neglected when an anaesthetic has been 
given, the surgeon often being inclined to handle the parts 
more roughly than he otherwise would ; such practice can- 
not be too severely condemned. 

Provisional Dressings in Cases of Fracture. 

It generally happens that fractures occur at localities more 
or less distant from the point where the treatment of the 
fracture is to be conducted, and the transportation of the pa- 
tient and the temporary dressing of the fracture are, therefore, 
matters of the first importance. In fractures of the upper 
extremities, if the fracture be simple, the clothing need not 
be removed, and the arm should be bound to the side by 
some article of clothing, or supported in a sling made from 
handkerchiefs or the clothing, and the patient can usually 



PROVISIONAL DRESSINGS. 



297 



Fig. 219. 



walk or ride for a short distance without much injury to the 
parts in the region of the fracture or inconvenience to him- 
self. When the bones of the lower extremities or the trunk 
are the parts involved, the transportation of the patient is a 
matter of more difficulty. When 
the bones of the trunk are in- 
volved, the part should be sur- 
rounded by a binder firmly 
pinned or tied, made from the 
clothing or from towels, or 
sheets or other strong materials 
which are at hand. When the 
bones of the lower extremity are 
involved, if the fracture be a 
simple one, the clothing need 
not be removed, and the motion 
of the fragments should be pre- 
vented by applying to the sides 
of the limb, extending above and 
below the seat of fracture, strips 
of wood, shingles, pasteboard, 
bundles of straw, strips of bark 
taken from trees, or bundles of 
twigs, these being held in place 
by handkerchiefs or strips torn 
from the clothing. Umbrellas 
or canes, or broomsticks (Fig. 
219), applied in the same man- 
ner, may be employed, the 
object of any of these dressings 

being to secure temporary fixation of the fragments of bone 
during the transportation of the patient. 

If the fragments are not fixed in some way, but are 
allowed to move about during the transportation of the 
patient, much damage may result to the soft parts surround- 
ing the fractured bones, and simple fractures may become 
compound ones by the bones being forced through the skin, 
the discomfort of the patient at the same time being much 
increased. 




Provisional dressing for fracture 
of the leg. (Esmarch.) 



298 FRACTURES. 

Having applied any dressing to bring about fixation of 
the fragments, the patient should next be placed upon a 
broad board or settee ; if a mattress cannot be obtained, the 
fractured limb should be laid upon a mass of clothing, or 
upon some straw, and he should be placed in a wagon or 
carried to the point where the subsequent treatment of the 
fracture is to be conducted. 



Reduction or Setting of Fractures. 

This should be effected as soon as possible after the occur- 
rence of the injury and as soon as the surgeon is prepared 
to' apply the dressings to keep the parts in their proper posi- 
tion ; reduction at an early period is less painful to the 
patient and is accomplished with more ease to the surgeon 
than at a later period when marked swelling and inflamma- 
tion are present at the seat of fracture. It consists in 
bringing the fragments by manipulation as nearly as possible 
in their normal position, and it is accomplished by extension 
and manipulation with the hands, care being taken to use as 
little force as possible to attain the object. Very little force 
is often required if the surgeon places the part in such a 
position as to relax the muscles which produce the displace- 
ment ; when this is accomplished the fragments can usually 
be pressed into, position by the fingers without the applica- 
tion of any considerable force. When the reduction of a 
fracture has been accomplished the fragments are retained in 
position by the application of various splints or dressings 
which serve to prevent their displacement. 

Materials and Appliances Used in the Dressing 
of Fractures. 

Fracture Bed. 

Many ingenious forms of beds have been devised for the 
use of patients suffering from fractures of the bones of the 
trunk and lower extremities, but a simple bedstead provided 



MATERIALS AND APPLIANCES USED. 299 

with a firm hair mattress having a perforation near its centre, 
into which is fitted a firm pad, and provided with a pan ^ 
which slides in a framework beneath a corresponding open- 
ing in the bedstead, will prove a useful appliance. The 
mattress is covered by a sheet perforated to correspond to 
the opening in the mattress, and when the pad is removed 
the evacuations of the patient are passed into the pan. 

In fractures of the trunk or lower extremities it will be 
found more convenient in handling the patient to use a single 
bed not over thirty-two or thirty-six inches in width, and it 
is not essential that the mattress be perforated, as a bed-pan 
can usually be slipped under the patient ; the mattress 
should be a firm one stuffed with hair. The use of an 
ordinary tin pie-plate covered with a piece of old muslin to 
receive the fecal evacuations may be substituted for the bed- 
pan and will be found in many cases more satisfactory, 
especially in the case of children suffering from fracture of 
the lower extremity. 

Splints. 

After the reduction or setting of the fragments in cases 
of fracture they are usually retained in position until union 
occurs by the use of splints held in position by means of 
bandages or strips of muslin. Splints may be made of wood, 
or of tin, lead, copper or wire which possess the requisite 
amount of firmness and permit of their being moulded to 
the part, which latter may be found useful in certain cases. 

Wooden splints. — The simplest and best splints are made 
from wood — white pine, willow or poplar being the best 
material to employ for their construction, being sufficiently 
strong to give fixation to the parts and at the same time 
being light. Splints made from smooth white pine, willow 
or poplar boards from one-eighth to one-half an inch in 
thickness may be employed in the form of straight or angu- 
lar splints, and their preparation is a matter of little diffi- 
culty. 

Wooden splints before being applied to the part should be 
well padded with cotton, wool, oakum, or hair, and where 



300 FRACTURES. 

lateral wooden splints are employed in the treatment of 
v fractures of the lower extremity it is usual to place bran- 
bags or junk-bags between the limb and the splint. The 
carved wooden splints which are sold by the instrument- 
makers are not to be recommended, as a rule, for unless the 
surgeon has a large number to select from it is rare that 
a splint can be obtained to accurately fit any individual 
case. 

Binder's board or pasteboard is an excellent material from 
which to construct splints ; it is first soaked in boiling water 
and when sufficiently soft is padded with cotton or a layer 
of lint and moulded to the part, and secured in position by 
a bandage : as it becomes dry it hardens and retains the 
shape into which it was moulded. 

Undressed leather is also an excellent material from 
which to construct splints ; it is applied by first soaking it 
in boiling water, and after padding it with cotton or lint 
it is moulded to the part and retained in position by a 
bandage. 

Felt made from wool saturated with gum shellac, pressed 
into sheets, is also a good material from which to construct 
splints. This material is prepared for application to the 
surface by heating it before a fire until it becomes pliable, 
or by dipping it into boiling water. 

Gutta-percha splints made from sheets of this material, 
in thickness from ^ to J- of an inch, may often be employed 
with advantage ; it is prepared for use by immersing it in 
hot water, when it becomes soft and can be moulded to 
the surface. Care should be taken that it is not allowed to 
become too soft by too long immersion to permit of its being 
conveniently handled. 

Paper splints made from layers of manilla paper stiffened 
with starch constitute a very fair substitute for some of the 
varieties of splints previously mentioned. 

Plaster- of -Paris, starch, chalk and gum, silicate of 
potassium or sodium may be employed for the construction 
of splints, either movable or immovable, in the treatment of 
fractures ; their method of preparation and application is 



MATERIALS AND APPLIANCES USED. 301 

described (p. 84 et seq.); the plaster-of-Paris dressing is 
the one which is most generally used at the present time. 

Fracture-box. — This is a form 
of splint used in the treatment of 
fractures of the lower extremity, 
and consists of a piece of board 
eighteen to twenty inches in length, 





with a foot-board firmly secured NSfi, ! gemrig, 

. -. . *\ 1 . t V 1_ . i 

at its lower extremity ; the sides _ . , ... 

. . . . i-i n Fracture-box with movable 

are secured by hinges which allow sides 

them to be raised or lowered (Fig. 

220). A fracture-box of greater length is required for the 

treatment of fractures about the knee-joint. 

Bran, Sand, or JtcnJc Bags. 

These are constructed by taking a piece of unbleached 
muslin five feet in length and fourteen and a half inches in 
width, doubling it and securing the free margins except at the 
mouth by stitches so as to form a bag ; the bag is then in- 
verted so that the edges of the seams are brought in the 
inner surface of the bag. The bags are next filled with 
dry sand, bran, or hair, or with straw, and the mouth of 
the bag is closed by stitches or by being tied with a string. 
Bran bags with splints or sand bags are frequently employed 
in the treatment of fractures of the femur. 

Bandages made of muslin are used to retain splints in 
the treatment of fractures, and are also sometimes applied 
directly to the injured part before the application of splints 
to control muscular spasm and limit the amount of swell- 
ing ; when a bandage is so used it is known as a primary 
roller. The use of the primary roller is sometimes of the 
greatest service in the dressing of fractures ; but its use in 
inexperienced hands has often been followed by such unfor- 
tunate results in the early treatment of fracture, or in cases 
which are not under constant observation, that I think it is 
a safe rule of practice to discard entirely the use of the 
primary roller. 

14 



302 FRACTURES. 

Compresses made from a number of folds of lint, of 
cotton or oakum, are often employed to retain fragments in 
position or to make localized pressure upon certain points 
in the treatment of fractures. The compresses are held in 
position by strips of adhesive plaster, by a few turns of a 
roller bandage, or by the splints. Compresses are some- 
times employed to protect bony prominences of the skeleton 
from the pressure of the splints ; but this purpose is often 
better effected by the use of small pieces of soap plaster 
spread on chamois fitted over the prominent points. 

Fig. 221. 




Rack for supporting bed-clothes in fracture of the lower extremity. 

A rack or cradle, made of wire or wooden hoops, is often 
employed to support the weight of the bed-clothes in the 
treatment of fracture of the lower extremity (Fig. 221). 



Dressing of Special Fractures. 
Fracture of the Nasal Bones. 

Fractures of the nasal bones are often accompanied with 
fractures involving the septum, the nasal process of the 
maxillary bone, and the nasal spine of the frontal bone. 

The treatment consists in replacing the fragments, if dis- 
placement exists, by manipulation with the fingers over the 
seat of fracture and by pressure made from within the nos- 
trils by a probe or a steel director. When the displace- 
ment is once corrected it is not apt to recur, and in the 
majority of cases no dressing is required. Before resorting 
to any manipulation within the nasal cavities the mucous 
membrane should be thoroughly cocainized to render the 



FRACTURE OF THE NASAL BONES. 



303 



operation painless to the patient. "When there is depression 
of the fragments or displacement of the septum, after cor- 
recting the deformity by raising the depressed fragment or 
bending the septum into place by a director, the parts may 
be held in position by packing the nasal cavity firmly with 
a strip of antiseptic gauze. 

In lateral displacements of the nasal bones from fracture, 
after reducing the displacement, a small compress held over 
the fragment by strips of adhesive plaster will be the only 
dressing required. 

Mason transfixes the nose, after reduction of the frag- 
ments, with a stout needle, and steadies the pieces with a 



Fig. 222. 




Mason's dressing for fractures of nasal bones. 



strip of plaster crossing the bridge of the nose and fastened 
to the ends of the needle. The needle is kept in position 
for eight or ten days (Fig. 222). Roberts, in cases in which 
there is a displacement of the cartilaginous portion of the 



304 FRACTURES. 

nose, after reducing the deformity, holds the parts in position 
by transfixing them with steel pins. 

Profuse hemorrhage sometimes occurs after fracture of 
the nasal bones and may require plugging of the nares to 
control it. 

Fractures of the nasal bones are usually firmly united in 
from ten to twelve days, and dressings may be dispensed 
with after this time. 

Fractures of the Malar Bone and Zygoma. 

These fractures are usually the result of direct force ; the 
displacement is upward or backward, and when the zygo- 
matic arch is broken the fragments from pressure upon the 
masseter muscle or on the tendon of the temporal muscle may 
interfere with the movement of the lower jaw in mastica- 
tion. This displacement is corrected by cutting down upon 
the fragment and elevating it or by passing a tenaculum 
into the fragment and raising it. 

Outward displacements may be corrected by pressure and 
the application of a compress. The dressing of these frac- 
tures after the correction of the deformity, consists in the 
application of a compress of lint over the seat of fracture, 
held in position by strips of adhesive plaster or a bandage. 
There is little tendency to recurrence of the deformity after 
it has been corrected, and union at the seat of fracture is 
usually firm at the end of three weeks. 

Fractures of the Upper Maxilla. 

These fractures may involve the body, the nasal processes 
or the alveolar processes. The displacement should be cor- 
rected and if any teeth have been displaced they should 
be replaced ; if there is comminution of the alveolus the 
teeth in the separate fragments may be fastened together by 
fine wire to fix the fragments and hold them in place ; and 
the teeth of the lower jaw should be brought up in contact 
with those of the upper jaw, and the jaws should be secured 
together by the application of a Barton's or a Gibson's 



FRACTURES OF THE LOWER MAXILLA. 305 

bandage (Fig. 223). Inter-dental splints, made of cork with 
grooves to fit the teeth, or of gutta-percha, are also em- 
ployed in the dressing of these fractures. The patient 
should not be allowed to move the jaw in mastication, and 

Fig. 223. 




Dressing for fracture of the upper jaw. 

should be nourished by liquid and semi-solid food which can 
be taken without removing any teeth to give space for its 
introduction. 

The bandage should be removed every second or third 
day, and after the face and neck have been sponged off with 
alcohol it should be reapplied. 

These fractures are usually firmly united at the end of 
four or five weeks, and dressings may be dispensed with at 
this time. 

Fractures of the Lower Maxilla. 

The lower jaw may be broken at or near the symphysis, 
the most usual seat of fracture being near the mental fora- 
men ; it is often broken at two places at once and the frac- 
tures are in many cases rendered compound by laceration of 
the mucous membrane, or the injury may consist in a separa- 
tion of a portion of the alveolar process of the bone. The 



306 



FRACTURES. 



dressing of a fracture of the lower jaw, after reducing the 
displacement and replacing any loosened or detached teeth, 



Fig. 224. 




Dressing for fracture of the lower jaw. 
Fig. 225. 




Four-tailed bandage applied for fracture of the lower jaw. 

consists in applying a pad of lint under the chin and bring- 
ing the jaw up against the upper jaw and holding the com- 



FRACTURES OF THE LOWER MAXILLA. 307 



press in place and securing the jaws firmly in contact by 
applying a Barton (Fig. 224), modified Barton or Gibson's 
bandage. The bandage should be removed and reapplied 
at the end of the second or third day, and at like intervals 
during the course of treatment. The patient should be fed 
upon a liquid or semi-solid diet, not being allowed to chew 
any solid food until the union at the seat of fracture has 
become firm. 

A very satisfactory temporary dressing for fracture of the 
lower jaw consists in the application of a four-tailed sling. 
(Fig. 225.) 

Some surgeons prefer to use an external splint moulded 
from pasteboard or gutta-percha fitted to the chin in the 

Fig. 226. 




Fig. 227. 



Shape of splint before being'fitted to chin. 

dressing of this fracture, this being padded with cotton and 
held in place by a Barton or Gibson bandage. (Fig. 227.) 
Where there is much difficulty in keeping the fragments in 
position the wiring together of the 
teeth may be employed, or the frag- 
ments may be perforated with a drill 
and held in place by a strong silver- 
wire suture ; inter-dental splints of 
metal or gutta-percha are also some- 
times used for this purpose. During 
the course of the treatment in frac- 
ture of the jaws the mouth often 
becomes very offensive from the fer- 
mentation of the saliva and discharges, and it is well to use 
frequently a mouth-wash of chlorate of potash, tincture of 
myrrh, glycerin and water. 




Splint moulded to fit chin. 



308 FRACTURES. 

The dressings for fracture of the lower jaw are usually- 
applied for four or six weeks, the union usually being quite 
firm at the end of this time. 



Fracture of the Hyoid Bone. 

In fracture of the hyoid bone, if displacement exists, its 
reduction is facilitated by pressure made with the finger in 
the pharynx. 

The treatment consists in enforced quiet and the use of 
opium if cough is a prominent symptom, and the inflam- 
matory symptoms may require the employment of active 
local treatment. A dressing may sometimes be employed 
with advantage, consisting of a splint of pasteboard or leather 
moulded to the anterior portion of the neck. 

Fractures of the Larynx or Trachea. 

In fractures of the larynx or trachea where there is little 
displacement and dyspnoea is not marked, the parts should 
be supported by the application of compresses of lint held 
in place by strips of adhesive plaster. If, on the other 
hand, the respiration is embarrassed or there is free expec- 
toration of blood, tracheotomy should be performed, and if 
the injury be seated in the larynx the displacement of the 
fragment may be overcome by manipulation with the finger 
or a director through the tracheal wound, or the larynx may 
be packed with a strip of antiseptic gauze to control hemor- 
rhage or hold the fragments in position, the patient in the 
meantime breathing through a tracheotomy tube secured in 
the tracheal wound ; the packing should be removed in a few 
days, the tracheotomy-tube being permanently removed as 
soon as the patient can breathe comfortably through the 
larynx with the tracheal wound closed. In fractures of the. 
trachea the opening into the trachea should be below or at 
the seat of injury. 



FRACTURES OF THE RIBS. 309 

Fractures of the Trunk 

Fractures of the Ribs. 

Fractures of the ribs are more frequent than fractures of 
any other bones of the trunk ; the ribs most commonly 
broken are those from the fourth to the tenth ; the most 
common seat of fracture is near the junction of the costal car- 
tilages or at the angle. The dressing of fractures of the ribs 
is best accomplished by enveloping 
the side of the chest on which the rib Fig. 228. . 

or ribs are broken with broad straps 
of adhesive plaster. The adhesive 
straps should be two and a half 
inches in width and long enough to 
extend from the spine to the middle 
of the sternum. The straps are 
warmed and the first strap is firmly 
applied a short distance below the 
seat of fracture, extending from the 
spine to the mid-sternal line; a .,, . . . , 

^ > Adhesive plaster dressing 

number ol ascending straps are for fracture of the ribs. 
applied in this way, each strap over- 
lapping the preceding one by about one-third of its width, 
until half the chest is covered in. (Fig. 228.) This dress- 
ing usually gives the patient much comfort, and the straps 
need not be renewed until they become slightly loosened, 
usually at the end of a week or ten days ; they should then 
be renewed in the same manner. 

The dressings for fractures of the ribs are usually dispensed 
with at the end of three or four weeks, as repair of the 
fracture is generally well advanced by this time. 

A satisfactory temporary dressing for fractures of the 
ribs consists in surrounding the chest by a broad binder of 
stout linen or muslin ; indeed, some surgeons prefer to 
employ this dressing during the course of treatment, but as 
a rule I think it is not as good a dressing as the adhesive 

14* 




310 FRACTUKES. 

plaster dressing, as the former confines the movements of 
both sides of the chest. 

Fractures of the Costal Cartilages. 

These fractures often take place at the junction of the 
cartilages with the ribs or in the body of the cartilages, and 
the union of the fracture usually takes place by the pro- 
duction of a mass of bone at the seat of fracture. The 
dressing for fractures of the costal cartilages consists in the 
application of strips of adhesive plaster applied in the same 
manner as for fracture of the ribs, and the dressing should 
be retained for about the same time. 

Fractures of the Sternum. 

Fractures of the sternum are rare injuries, but diastasis 
of the bones of the sternum is a more common accident. 
The dressing for either variety of injury is the same, and 

Fig. 229.- 




Adhesive piaster dressing for fracture of the sternum. 

consists in the application of a compress over the seat of 
fracture held in place by a broad bandage, or, better, by 
strips of adhesive plaster (Fig. 229), applied so as to cover 
and fix the anterior portion of the chest, covering the entire 
length of the sternum. This dressing should be retained 



FRACTURES OF THE SACRUM AND COCCYX. 311 

for at least four weeks, being renewed if it becomes loose at 
the end of a week or ten days. 



Fractures of the Pelvis. 

These fractures are often serious injuries from implication 
of the pelvic viscera. The reduction of the displacement should 
first be accomplished as far as possible by external manipu- 
lation, together with internal manipulation by the fingers 
introduced into the rectum, or into vagina in the female. 
The patient should be placed upon a firm bed on his back, 
with the knees slightly flexed over a pillow, and the parts 
should be kept at rest by surrounding the pelvis with broad 
straps of adhesive plaster or a stout muslin binder, or by a 
firmly applied padded pelvic belt. The hip-joints should 
be kept at rest by the application of pasteboard splints or 
by sand-bags. The dressings should be retained for a period 
of at least six weeks. 

When these fractures are complicated by injury of the 
pelvic viscera various operative procedures may be required, 
which will compel the surgeon to modify the method of 
dressing. 

Fractures of the Sacrum and Coccyx. 

The dressing of these fractures, after effecting reduction 
of the fragments as far as possible by pressure within the 
rectum, and, when the sacrum is involved, the application 
of broad adhesive straps, or of a padded belt, should be em- 
ployed, and the patient should be kept at rest in bed. 
When the coccyx only is fractured, after reduction of the 
displacement, the patient should be confined to bed and the 
bowels should be kept at rest by the use of opium by sup- 
pository. The patient should be kept at rest for three or four 
weeks, and, in case of fracture of the sacrum, the dressings 
should be retained for this time. 



312 FRACTURES. 



Fractures of the Vertebra. 

Fractures of the vertebrae are always most serious injuries, 
not only from the injury of the bones themselves, but also 
from the damage to the spinal cord, membranes, and nerves, 
which often accompanies them. 

In transporting, or turning in bed, a patient suffering from 
fracture of the vertebrae, great care should be exercised, for 
rough or sudden motions might cause a displacement of the 
fragments which might, by injury of, or pressure upon, the 
spinal cord, rapidly prove fatal. 

In the treatment of fractures of the spine, if the deformity 
is marked, efforts should be made to reduce it by extension 
and counter-extension, and the result may be successful, 
especially if the fracture be associated with a dislocation of 
the vertebrae. In some cases the use of permanent exten- 
sion by means of weights attached to the legs, shoulders, 
and chest by adhesive plaster and bandages has been suc- 
cessful in reducing the deformity. 

The patient should be placed upon his back upon a bed 
with a hair mattress, or better, if it can be obtained, a 
water-bed, which consists of a rubber mattress filled with 
water, which distributes the weight of the patient's body 
evenly over the surface. Whatever form of bed be used, the 
greatest care should be exercised to keep the patient abso- 
lutely clean, and the parts of the body or limbs which are 
exposed to pressure should be frequently bathed with alcohol 
or soap liniment, and to distribute the pressure, small pads 
should be placed under the parts and changed at intervals. 
These precautions are necessary to prevent, if possible, the 
formation of extensive bedsores, which are a frequent and 
troublesome complication of these injuries. 

The bowels should be carefully watched, and, if constipa- 
tion is present, it should be relieved by the use of enemata ; 
and, as it is not desirable to lift the patient to slip a bed-pan 
under him, the discharges can be received in a flat tin plate 
pushed under the thighs and buttocks, or on pads of oakum 
or old muslin. 



FRACTURES OF THE SKULL. 313 

The care of the bladder is also a matter of the greatest 
importance ; the retention which at first exists should be 
relieved by the use of a flexible catheter introduced with 
great gentleness, and when incontinence supervenes the 
catheter should also be used at intervals ; the employment 
of a soft instrument, if used with care, is not apt to produce 
any injury to the urethra or bladder. 

The employment of a plaster-of-Paris jacket has been 
followed, in some cases, by good results, and it may be 
applied early in the case, or it may be used after the patient 
has been kept in the recumbent posture for some weeks ; by 
its use it is often possible to get the patient out of bed and 
allow him to sit in a chair. 

In fractures involving the cervical vertebrae, care should 
be exercised in lifting or moving the head, and it is often of 
advantage in these cases to apply short sand-bags to the 
sides of the neck and head, to give additional fixation to the 
parts while the patient is in the recumbent posture, or, if he 
is allowed to get out of bed, to apply a moulded leather or 
pasteboard splint to the neck, shoulders, and back of the 
head for the same purpose. 

Trephining of the spine in cases of fracture of the verte- 
brae, to remedy the displacement and relieve the cord from 
pressure, has been recommended and employed in some 
cases, and although the operation under strict antiseptic 
methods is not attended with much risk, the results obtained 
up to the present time scarcely seem to warrant its per- 
formance. 

The course of treatment in cases of fractures of the ver- 
tebrae, if the patient does not succumb to the injury in a 
few days or weeks, often extends over many months, and 
recovery is often more or less incomplete as regards the 
function of the parts below the seat of fracture. 

Fractures of the Skull. 

The treatment of fractures of the skull, whether simple 
or compound, depends largely upon the nature of the injury 
and the condition of the cranial contents. In simple frac- 



314 FRACTURES. 

tures unaccompanied with cerebral symptoms no special 
dressing is required, but in compound fractures where loose 
fragments are present, these should be removed; and if 
there is no depression of the fragments, and if no cerebral 
symptoms are present, the wound should be drained and 
closed and dressed antiseptically, the dressings being held 
in place by a recurrent bandage of the head. 

The patient should be put to bed and the use of an ice-cap 
to the head is often of service. The diet should be restricted 
and calomel and opium and bromide of potassium should be 
administered ; it is well to keep the patient for a few weeks 
in a quiet and darkened room. Where cerebral symptoms 
are present, either in simple or compound fractures, and 
trephining is resorted to, the dressing of the wound is 
similar, and the same general treatment should be adopted. 
In all cases of fracture of the skull, whether subjected to 
operative treatment or not, it is well to keep the patient at 
rest in bed for three or four weeks, and he should be cau- 
tioned to avoid excesses and should not resume active work 
for some months. 



Fractures of the Upper Extremity. 

Fractures of the Clavicle. 

Fractures of the clavicle may be complete or incomplete, 
and in the latter variety of injury, the deformity is not 
usually very marked. The indications for treatment in 
complete fractures of the clavicle are to relax the sterno- 
cleido-mastoid muscle, to prevent the weight of the arm on 
the injured side from dragging down the outer fragment of 
the clavicle, and by fixing the scapula, to carry the attached 
external fragment outward and forward. A large number 
of dressings have been devised and used to accomplish these 
objects. The treatment of fractures of the clavicle by 
position is accomplished by placing the patient in bed on 
his back upon a firm mattress with a low pillow under his 
head, and the arm on the side of injury should be fastened 



FRACTURES OF THE CLAVICLE. 315 

to the side of the chest by a few circular turns of a ban- 
dage passing around the arm and chest ; the deformity is 
usually very satisfactorily reduced upon the patient assum- 
ing this position, and after three weeks' rest in this position 
the union is generally sufficiently firm to allow the patient 
to get out of bed and be about with the arm bound to the 
side or carried in a sling or with a Yelpeau bandage applied, 
without any recurrence of the deformity. 

A satisfactory temporary dressing for fractures of the 
clavicle consists in the application of a four-tailed bandage ; 
the bandage is made from a piece of muslin two yards in 




Four-tailed bandage for fracture of clavicle. 

length and fourteen inches in width ; a hole is cut in its 
centre about four inches from its margin, to receive the 
point of the elbow ; the bandage is then split into four tails 
in the line of the hole and to within six inches of it ; the 
body of the bandage should be applied so that the point of 
the elbow rests in the hole, and a folded towel being placed 
in the axilla, the lower tails should be carried, one anteriorly, 
the other posteriorly, diagonally across the chest and back 
to the neck on the side opposite the seat of fracture and 
secured ; the remaining tails are next carried around the 



316 



FRACTURES. 



lower part of the chest and secured so as to fix the arm to 
the side of the body. (Fig. 230.) 

In some cases the deformity is corrected by the applica- 
tion of a posterior figure-of-eight bandage, the forearm on 
the side of injury being carried in a sling. (Fig. 231.) 



Fig. 231. 




Posterior figure-of-eight dressing for fracture of the clavicle. (Hamilton.) 



Sayres dressing for fracture of the clavicle consists of 
two strips of adhesive plaster three and a half inches wide 
and two yards in length. The first strip is looped around 
the arm just below the axillary margin, and is pinned or 
sewed with the loop sufficiently open not to constrict the 
arm. The arm is then drawn downward and backward 
until the clavicular portion of the pectoralis major muscle 
is put sufficiently upon the stretch to overcome the action 
of the sterno-cleido-mastoid muscle, and in this way draws 
the sternal fragment of the clavicle down to its place. The 
strip of plaster is then carried completely around the body 
and pinned or stitched to itself on the back. (Fig. 232.) 
The second strip is next applied, commencing upon the 
front of the shoulder of the sound side ; thence it is carried 
over the top of the shoulder diagonally across the back, 



FRACTURES OF THE CLAVICLE 



317 



under the elbow, diagonally across the front of the chest to 
the point of starting, where it is secured by pinning or 
sewing. A slit is made in this strip to receive the point of 
the elbow. Before the elbow is secured by the plaster, it 
should be pressed well forward and inward. (Fig. 233.) 

Velpeaus dressing may also be used in the treatment of 
fractures of the clavicle. (Fig. 234.) A compress may also 



Fig. 232. 



Fig. 233. 





Sayre's dressing for fracture of the 
clavicle. First strip applied. 



Sayre's dressing for fracture of the 
clavicle. Second strip applied. 



be secured by the vertical turns of this bandage over the 
seat of fracture if needed. The application of the bandage 
is described (p. 55). 

In any form of dressing in which the arm is held against 
the side of the chest, it is well to apply a folded towel or 
piece of lint between the arm and chest to prevent the sur- 
faces from becoming excoriated. 

A modified form of the Velpeau dressing for fracture of the 



318 



FRACTURES. 



Fto. 234. 




Velpeau's dressing for fracture 
of the clavicle. 



clavicle is applied as follows : A soft towel or piece of lint is 
placed against the side of the body and over the front of 

the chest, and held in position by 
a strip of adhesive plaster ; the 
arm is next placed in the Yelpeau 
position, a good-sized pad of lint 
is next applied over the scapula, 
and this is held in place by a 
broad strip of adhesive plaster two 
and a half inches in width and 
one and a half yards in length ; 
this strip is continued downward 
and forward so as to pass over 
the point of the elbow, and is 
carried diagonally across the chest 
to the shoulder of the opposite side 
and is secured, a slit being cut in 
it to receive the point of the 
elbow ; a compress of lint is next 
placed over the seat of fracture 
and held in place by a strip of adhesive plaster ; an additional 
strip of plaster is next carried from the spine around the 
arm and chest and secured on the opposite side of the chest ; 
circular turns of a roller bandage are then passed around 
the chest, including the arm, from below upward until the 
arm is securely fixed to the body, and the dressing is fin- 
ished by making one or two turns of the third roller of 
Desault. (Fig. 235.) • 

In the treatment of fractures of the clavicle in children 
the Velpeau or modified Velpeau dressing will be found to 
be the most satisfactory dressing to employ, and as these 
patients are particularly apt to disarrange their dressings 
it is well to render the dressing additionally secure by 
applying a few broad strips of adhesive plaster over the 
turns of the roller bandage, the strips following the turns of 
the bandage. 

The removal of dressings and their reapplication will 
depend upon the comfort of the patient and the manner in 
which they keep their position. As a rule in fractures of 



FRACTURES OF THE CLAVICLE 



319 



the clavicle the dressings are removed at the end of the 
second or third day, the parts are inspected, and the skin is 
sponged off with dilute alcohol or whiskey ; the dressings 
are then reapplied, and if they are comfortable and the 



Fig. 235. 




Modified Velpeau dressing for fracture of the clavicle. 



parts are in good position, the dressings are made at less 
frequent intervals until union is completed at the seat of 
fracture. 

Union in cases of fracture of the clavicle is generally 
quite firm at the end of four or five weeks, and at this time 
the dressings may be removed, and the patient should carry 
the arm of the affected side in a sling for several weeks, 
and should not undertake any work requiring forcible move- 
ments of the arm until eight or ten weeks have elapsed 
from the receipt of the injury. 

The time required for union in fractures of the clavicle 
in children is somewhat shorter ; the dressings may be 
removed at the end of three weeks. 



320 



FRACTURES. 



Fractures of the Scapula. 

Fractures of the scapula may involve the body, neck, 
acromion or coracoid process of the bone. Fractures of this 
bone are quite rare. 

Fracture of the Body of the Scapula. 

In dressing this fracture, if deformity is present, it is re- 
duced by manipulation, and compresses of lint are placed 
above and below the seat of fracture and held in place by 
adhesive strips ; the arm is next fixed to the side of the 
body by spiral turns of a roller bandage passing around 
the arm and chest, and the forearm is supported in a sling. 

Fracture of the Week, Acromion or Coracoid Process 
of the Scapula. 

These fractures may be dressed by placing a pad of lint 
or a folded towel in the axilla and binding the arm to the 



Fig. 23( 




Velpeau dressing for fracture of the scapula. 

body by spiral turns of a roller bandage passing around 
the arm and chest and supporting the forearm in a sling. 



FRACTURES OF THE HUMERUS. 



321 



Or these fractures of the scapula may be dressed by first 
placing a pad of lint or a folded towel in the axilla and 
then securing the arm in the Velpeau position by the appli- 
cation of a Yelpeau's bandage. (Fig. 236.) In fractures 
of the acromion or coracoid processes the union is usually 
fibrous. In the treatment of fractures of the scapula the 
dressing: should be retained for about four weeks. 



Fractures of the Humeru: 



Fig. 23; 



Fractures of the humerus may involve the upper ex- 
tremity, the shaft or the lower extremity of the bone. 

Fractures of the Upper Extremity of the Humerus include 
fractures of the head and anatomical neck of the bone, 
fractures through the tuberosities, fractures through the sur- 
gical neck of the humerus, and epiphyseal fracture or disjunc- 
tion of the upper epiphysis of the humerus. 

The most satisfactory dressing for all fractures of the 
humerus above the upper third of the bone is applied as 
follows : A primary roller should be evenly 
applied from the tip of the fingers to the 
seat of the fracture, the arm being flexed 
at the elbow before the bandage is carried 
above this point, to prevent the danger- 
ous constriction which might result if 
the bandage were applied with the arm 
in the straight position, and it were after- 
wards flexed at the elbow. A folded towel 
or a thin pad of lint should next be placed 
in the axilla and over the outer surface of 
the chest, to furnish a firm basis of sup- 
port for the humerus and also^to prevent 
excoriation from the contact of the skin 
surfaces. A splint of pasteboard, felt or 
leather (Fig. 237) is next moulded to the 
shoulder and arm; this should be long 
enough to extend some distance below the seat of fracture 
and wide enough to cover in about one-half of the circum- 




Moulded splint for 
shoulder and arm. 



322 



FRACTURES. 



ference of the arm, and is padded with cotton and fitted to 
the shoulder and arm. The splint and arm are next secured 
to the side of the body by spiral turns of a roller bandage 
including the arm and chest in its turns and applied from 
the elbow to the top of the shoulder. The forearm is car- 
ried in a narrow sling suspended from the neck (Fig. 238). 
This dressing should be removed at the"end of twenty-four 

Fig. 238. 




Dressing for fracture of the upper extremity of the humerus. 

or forty-eight hours, and after the parts have been inspected 
and sponged over with alcohol, the dressings should be reap- 
plied in the same manner, and if the -patient is comfortable 
they need not be disturbed again for three or four days, 
subsequent dressings being made at the same intervals. 
Union in fractures of the upper extremity of the humerus, 
except in intra-capsular fracture, in which bony union is 
the exception, is usually quite firm at the end of five or six 
weeks, and the dressings can be dispensed with at this time. 

Fractures of the Shaft of the Humerus. 

The dressing consists in the application of a primary roller 
from the tips of the fingers to the seat of fracture; a short 



FRACTURES OF THE HUMERUS. 



323 



well-padded wooden splint extending from the axilla to a 
point a little above the internal condyle is next placed on 
the inner surface of the arm and against the chest ; a 
moulded pasteboard or felt splint, fitted to the shoulder and 
outer side of the arm and extending a short distance below 
the seat of fracture, is padded with cotton and applied to 
the shoulder and arm. The splints are held in position and 
the arm is secured to the body by spiral turns of a roller 
bandage carried around the chest and arm, and the forearm 
is carried in a sling suspended from the neck. The dressing 
is much the same as that for fracture of the upper part of the 
humerus, with the addition of the short internal splint. 

Fractures of the shaft of the humerus may also be dressed 
by first applying a primary roller and then placing the fore- 
arm and arm upon a well-padded internal angular splint. 
(Fig. 239.) Care should be taken to see that the end of 



Fig. 239. 




Internal angular splints. 

the splint extends only to the axilla and does not press upon 
the brachial vein. A pasteboard or felt moulded splint is 
next applied to the shoulder and outer side of the arm. 
The splints are held in position by turns of a roller bandage 
beginning at the fingers and carried up to the shoulder. 
(Fig. 240.) The arm is supported by a sling applied at the 
wrist, and sometimes for additional security the arm is se- 
cured to the side of the body by spiral turns of a bandage 
carried around the arm and chest. The after-treatment of 



324 FRACTUEES. 

these fractures as regards the removal and renewal of the 
dressings is the same as in cases of fracture of the upper 
portion of the humerus. 

Fig. 240. 




Dressing for fracture of the shaft of the humerus with internal 
angular splint. 

In fractures of the shaft of the humerus the dressings 
should be retained for five or six weeks. 



Fractures of the Lower Extremity of the Humerus. 

These include fractures at the base of the condyles, 
splitting fractures between the condyles or those of the 
internal or external condyle, and epiphyseal fracture or 
disjunction of the lower epiphysis of the humerus. 

In dressing fractures of the lower extremity of the 
humerus, if a primary roller is employed it should be 
carried up only to the elbow; the displacement is reduced 
by extension and manipulation, and before applying any 
splint it is well in many cases to apply over the region of 
the fracture several folds of lint saturated with lead-water 



FRACTURES OF THE HUMERUS. 



325 



and laudanum, and to cover this dressing with waxed paper 
or rubber tissue to diminish as far as possible the swelling, 
which is very marked after these injuries. An anterior 
angular splint (Fig. 241) well padded with cotton or oakum 



Fig. 241. 




Anterior angular splint. 



is next applied and held in position by the turns of a roller 
bandage applied from the fingers to the upper portion of the 
splint. (Fig. 242.) These fractures may also be dressed 
with a well-padded internal angular splint, this splint being 



Fig. 242. 




Dressing for fracture of the lower extremity of the humerus with 
anterior angular splint. 



substituted by an anterior angular splint at the end of ten 
days or two weeks. 

These fractures may also be dressed by placing the arm 
in a posterior angular trough (Fig. 243) made of pasteboard 

15 




326 FEACTURES. 

or leather. Some surgeons prefer to dress fractures of the 
condyles of the humerus with the arm in the extended posi- 
tion upon a straight anterior splint, 
or with short, narrow pasteboard 
splints applied around the joint, as 
favoring more accurate coaptation of 
the fragments. If this position is 
employed a straight wooden splint 
is applied to the anterior surface of 
the arm and forearm, or moulded 
splints of pasteboard may be used, 
and after the union is moderately 
firm, at the end of two weeks, the elbow should be flexed 
and kept in this position during the remaining time of the 
treatment. 

When fractures of the lower extremity of the humerus 
involve the elbow-joint a certain amount of impairment of 
joint-motion is apt to occur either from ankylosis or from 
displacement- of the fragments which in many cases it is 
impossible to completely reduce, so that flexion and exten- 
sion of the joint is restricted. Bearing these facts in mind, 
it is well to make passive motion in these cases as early 
as the second or third week. It is well to explain to 
the patient or his friends that impairment of joint-motion 
may result in these fractures in spite of the greatest skill 
and care in the treatment. In a case of fracture in the 
region of the condyles of the humerus the dressings should 
be removed in twenty-four hours and it should be re-dressed 
in the same manner, and if the swelling does not increase 
and the dressing is comfortable to the patient it should after- 
ward be dressed at less frequent intervals; the union is 
generally quite firm at the end of four weeks and the splint 
may be removed at this time. Fractures of the condyles of 
the humerus are very common in children and epiphyseal 
disjunctions of the lower epiphyses are also met with ; the 
dressing of these injuries in this class of patients is similar 
to that described for fractures of the condyles of the 
humerus. 



FRACTURES OF THE OLECRANON 



32^ 



Fractures of the Olecranon Process of the Ulna. 

Fractures of the olecranon may consist in simply a sepa- 
ration of the cortical layer of bone over the summit of the 
process to which the triceps is principally attached, or the 
line of fracture may pass through the sigmoid fossa. 

Fractures of the olecranon are dressed with the arm 
slightly flexed at the elbow, or with it completely extended: 

Fig. 244. 




Adhesive strap applied to draw fragment downward. 

the former position is possibly a little less irksome to the 
patient. The separation of the fragment by the action of 

Fig. 245. 




Fracture of olecranon dressed in the extended position. 



the triceps muscle is usually not very marked ; but, if the 
displacement is marked, it may in a measure be overcome by 
the use of a compress above the fragment, over which figure- 
of-eight strips of adhesive plaster are fastened to draw it 



328 FRACTURES. 

down into position (Fig. 244). A primary roller should 
then be carefully applied to the forearm and arm with figure- 
of-eight turns at the elbow to reinforce the action of the 
strips of plaster, and a well-padded straight wooden splint 
extending from the upper third of the arm to the ends of 
the fingers is next securely fastened to the arm by the turns 
of a roller bandage (Fig. 245). 

This fracture may also be dressed by first applying a pri- 
mary roller up to the elbow, and then placing the arm upon 
a well-padded anterior obtuse-angled splint, or a straight 
splint with a good-sized pad of lint or oakum fastened at a 
point corresponding to the position of the flexure of the 
elbow. When either of these splints is placed upon the arm 
a position of moderate flexion is obtained. A compress of 
lint is next placed above the fragment, if there is displace- 
ment, and one or two narrow strips of adhesive plaster are 
fastened to this and passed obliquely downward and attached 
to the splint on either side. The splint is then securely 
fastened to the arm by the turns of a roller bandage applied 
from the fingers to the upper end of the splint. 

The dressings in a case of fracture of the olecranon should 
be removed at the end of twenty-four or thirty -six hours, or 
sooner if there is evidence of swelling of the tissues in the 
region of the fracture, and they should be reapplied in the 
same manner. If the dressing is comfortable to the patient, 
and there is no evidence of swelling, the subsequent dressings 
should be made at less frequent intervals ; the dressings are 
usually retained in this fracture for five or six weeks. 
Passive motion should not be made until this time, as flexion 
of the elbow tends to separate the fragments, unless union 
has taken place. The repair of a fracture of the olecranon 
is, in most cases, by fibrous union, but in a few instances 
bony union has been found to have taken place. 

Fractures of the Coronoid Process of the Ulna. 

Fractures of the coronoid process are rarely met with, and 
their dressing is accomplished by placing the arm in a flexed 



FRACTURES OF BOTH BONES OF FOREARM. 329 

position and applying a well-padded internal right-angled 
splint, or a posterior right-angled splint, and securing it to 
the arm by the turns of a roller bandage. A moulded paste- 
board or leather gutter may be substituted for the angular 
splints. The dressings should be changed at intervals, and 
after their removal at the end of three or four weeks, passive 
motion should be practised. 

Fractures of the Head and Neck of the Radius. 

These fractures are also quite rare, and, when met with, 
should be dressed, after reducing the fragments by manipu- 
lation, by flexing the elbow and keeping it in this position 
by the application of a well-padded anterior right-angled 
splint, the splint being firmly secured in position by the 
turns of a roller bandage applied from the tips of the fingers 
to the upper end of the splint. The splint should be 
changed at intervals, and should not be permanently re- 
moved for four weeks, at which time passive motion, consist- 
ing in flexion and extension at the elbow and pronation and 
supination of the forearm, should be made. (Fig. 242.) 

An internal angular splint applied to the inner surface of 
the forearm and arm may also be used in the treatment of 
these fractures. (Fig. 240.) 

Fractures of Both Bones of the Forearm. 

These fractures are often met with as the result of direct 
or indirect violence, and after reducing the displacement, 
which is always marked when both bones are broken, and is 
not so marked when one bone only is broken, by making 
extension from the hand and by manipulation; the forearm 
is placed in the supine position or in a position between pro- 
nation and supination. The supine position is, as a rule, to 
he preferred in any fracture of the radius, as the upper 
fragment is supinated by the action of the biceps and 
supinator brevis muscles, and, therefore, unless the lower 



330 FRACTURES. 

fragment be placed in the supine position union with rotary 
deformity will almost inevitably ensue. 

Two straight wooden splints, well padded, a little wider 
than the forearm, are employed. The anterior splint should 
be long enough to extend from the elbow to the tips of the 
fingers, and the posterior splint should extend from the 
elbow to the wrist. A primary roller should never be ap- 

Fig. 246. 




Dressing for fracture of both bones of the forearm. 

plied to the forearm in dressing these fractures, as its applica- 
tion diminishes the interosseous space and its use has been 
followed by gangrene of the hand and forearm. In apply- 
ing the anterior splint to the palmar surface of the forearm 
and hand care should be taken to see that the upper end 
of the splint does not press upon the brachial artery and 
vein at the elbow when the forearm is flexed ; the posterior 
splint is next applied from the elbow to the wrist and the 
splints are held in position by the turns of a bandage car- 
ried from the fingers to the elbow. (Fig. 246.) 

In fracture either of the shaft of the radius or of the 
ulna alone, the deformity is usually not so marked as when 
both bones are broken at the same time, the unbroken bone 
acting as a splint ; the dressing for these fractures is the 
same as for fracture of both bones of the forearm. 

The dressing should be removed in twenty-four or thirty- 
six hours, and after inspecting the parts and sponging them 



FRACTURES OF LOWER END OF RADIUS. 331 

with dilute alcohol the splints should be replaced in the same 
manner and secured, and the dressings should be removed 
and renewed at intervals of two or three days for two weeks 
at least, and after this time the dressings should be made 
at less- frequent intervals. The time required for union in 
these fractures is usually five or six weeks, and the splints 
should be retained for this time. 

Fractures of the forearm should be seen by the surgeon 
frequently for the first two weeks of the treatment, for it 
is in these fractures that the most unfortunate results have 
occurred from neglect of this precaution. 

In children incomplete or green-stick fractures of the 
bones of the forearm are very common : their dressing, after 
reducing the deformity, which consists in bending the bones 
back into place, which often converts the incomplete frac- 
ture into a complete one, is accomplished in the same man- 
ner as described above. In these patients there is a great 
tendency to displace the splints or rather to draw the fore- 
arm out of the splints, and to prevent this I often employ 
an anterior angular splint, in place of the straight an- 
terior splint, the upper portion of which, being fastened to 
the arm, prevents the child from dragging the arm out of 
the dressings. 

Fractures of the Lower End of the Radius. 

The most common fracture of the radius is one situated 
from one-half of an inch to one and one-half inches above 
the lower articular surface of the bone, the line of fracture 
being more or less transverse, although it may in some cases 
be slightly oblique ; the characteristic deformity in this 
fracture is represented in Fig. 247. 

The most important point in the treatment of this frac- 
ture is to effect complete reduction before the application of 
any splint; this is done by making extension from the hand, 
and at the same time, by extending and flexing the wrist 
and by manipulation, the deformity can usually be com- 
pletely reduced. The arm should then be brought into the 



332 



FRACTURES. 



position of supination, and a firm compress of lint is next 
placed over the lower end of the upper fragment on the 



Fig. 247. 




Fracture of the radius near its lower extremity. 



Fig. 248. 




Position of compresses in Colles's fracture. 
Fig. 249. 




Bond's splint 



palmar surface of the forearm ; a second compress is then 
placed over the upper end of the lower fragment (Fig. 248), 
and a well-padded Bond splint (Fig. 249) is applied to the 



FRACTURES OF LOWER END OF RADIUS. 333 

palmar surface of the arm and held in place by the turns 
of a roller bandage. (Fig. 250). 

Fig. 250. 




Dressing for fracture of the lower end of the radius. 

Many surgeons treat this fracture with the hand in a 
position between pronation and supination, the thumb point- 
ing upward. A substitute for Bond's splint may be pre- 
pared by fastening a roller bandage obliquely upon a straight 
wooden splint as suggested by Dr. Hays. (Fig. 251.) 



Fig. 251. 




Substitute for Bond's splint. 

Two straight splints with compresses are also employed 
in the treatment of this fracture, and a vast number of 
splints have been devised ; among these may be mentioned 
those of Gordon, Coover, and the metal splint of the late 
Dr. R. J. Levis. The most important point in the treat- 
ment of this fracture is the complete reduction of the de- 
formity at the first dressing, and if this has been satisfac- 

15* 



334 FRACTURES. 

torily done almost any splint may be used with a good 
result, and indeed some surgeons use no splint, applying 
only a compress over the palmar fragment, held in place by 
a strip of plaster, the arm being carried in a sling. 

The after-treatment of these fractures consists in removing 
the splint and compresses after twenty-four or thirty-six 
hours and in sponging the surface of the skin with dilute 
alcohol, and the compresses and splint should then be reap- 
plied in the same manner ; the fracture should be dressed 
every second or third day for the first two weeks, and after 
this time it should be dressed at less frequent intervals. 
Union is usually quite firm at the end of four weeks, and 
the splint should be dispensed with at this time. A certain 
amount of stiifness of the wrist and fingers is apt to follow 
this fracture, which is usually soon overcome by passive 
motion and physiological use of the parts. 

In children epiphyseal separations or fractures of the 
lower epiphysis of the radius are often met with, and their 
treatment is similar to that described above ; a Bond splint 
with compresses or two straight splints with compresses 
being the most satisfactory dressing to employ in this in- 
jury, the dressings being retained for three weeks. 

Fractures of the Carpal Bones. 

These fractures are usually compound or open fractures, 
and are so frequently associated with extensive laceration of 
the arm and hand that operative measures have to be re- 
sorted to ; but if such is not the case they are dressed, when 
compound, with an antiseptic dressing, and the hand and 
forearm are supported upon a well-padded palmar splint 
held in place by a roller bandage; more or less impairment 
in the motion of the wrist is apt to follow these fractures. 
In simple fractures of the carpal bones the use of an evapo- 
rating lotion for a few days, in connection with the splint 
just mentioned, will be found useful. The dressings should 
be retained for three or four weeks, and after their removal 
passive motion should be employed to overcome as far as 
possible the joint-stiffness resulting. 



FRACTURES OF THE PHALANGES. 



335 



Fractures of the Metacarpal Bones. 

These fractures are often met with as the result of direct 
or indirect force applied to the metacarpal bones. The 
treatment of fractures of the metacarpal bones consists in 
first reducing the deformity, which is usually an angular 
one, the projection of the angle being toward the back of 
the hand ; this is reduced by pressure with the fingers, and 
the hand and forearm should then be placed upon a palmar 
splint (Fig. 252) with a pad of oakum or cotton under the 



Fig. 252. 




Agnew's splint for fracture of the metacarpal bone 



a compress of lint is next placed over the seat of 
fracture, and the hand and forearm are bound to the splint 
by the turns of a roller bandage. (Fig. 253.) At the end 



Fig. 253. 




Dressing for fracture of the metacarpal bones. 

of three weeks union at the seat of fracture is usually quite 
firm, and the splint should be dispensed with at this time. 

Fractures of the Phalanges. 



The treatment of fractures of the phalanges consists in 
reducing the displacement by extension and manipulation, 



336 FRACTURES. 

and in placing the finger in a moulded gutta-percha or paste- 
board splint (Fig. 254), and securing the splint in position 

Fig. 254. 




Gutta-percha splint for fracture of phalanx. (Hamilton.) 

by the turns of a roller bandage. When the proximal 
phalanx is fractured a narrow, padded, wooden splint extend- 
ing from the end of the finger to the wrist should be applied 
upon the palmar surface of finger and hand, and a short 
dorsal splint should also be used ; if there is a tendency to 

Fig. 255. 




Dressing for fracture of phalanx with anterior and posterior splints. 

lateral displacement short lateral splints should also be 
employed, and the splints should be held in place by strips 
of plaster or by a roller bandage. (Fig, 255.) 

Union in fractures of the phalanges is usually quite firm 



FRACTURES OF THE FEMUR. 



337 



at the end of three weeks, and the splints can be dispensed 
with at that time. 



Fractures of the Lower Extremity. 

Fractures of the Femur. 

Fractures of the upper extremity of the femur are those 
involving the neck, great trochanter, and upper end of the 
shaft of the bone. 

In dressing fractures of the upper extremity of the femur 
the patient should be placed in bed upon a firm mattress, 
and an extension apparatus made from adhesive plaster 
should be applied to the leg, extending as far as the knee- 
joint. The extension apparatus is constructed by taking a 
piece of adhesive plaster two and a half inches in width 
and long enough to extend from the outer side of the knee 



Fig. 256. 




Adhesive plaster extension apparatus applied to limb. (Ashhcrst.) 

to four inches below the sole of the foot, and from this point 
back to the inner side of the knee ; in the centre of this 
strip is placed a block of wood, two and a half inches wide 
and four inches in length, with a perforation in its centre; 
the block and the inner surface of the strip on each side are 
next faced with a similar strip of adhesive plaster to a 



338 FRACTURES. 

point about an inch above each malleolus ; a few straps are 
next wound around the wooden block to fix the previously 
applied straps; the strip of plaster is next warmed and 
applied to the sides of the leg and held in position by three 
strips of adhesive plaster carried around the leg at intervals 
(Fig. 256), and the plaster is made additionally secure by 
the application of a roller bandage applied to the foot and 
leg and carried up to the knee. Through the perforation in 
the block or stirrup is fastened a cord which passes over a 
pulley attached to the bed, and to this cord is attached the 
extending weight. The extension apparatus being applied, 
lateral support is given to the leg and thigh by sand-bags 
applied on either side; the outer sand-bag should extend 
from the foot to the axilla, and the inner one from the foot 
to the groin. A weight of five or ten pounds is attached 
to the extending cord, and the lower feet of the bed should 
be raised on blocks a few inches high to prevent the patient 
from slipping down in bed ; a pad of oakum or cotton 
should also be placed under the tendo Achillis to relieve the 
heel from pressure. This dressing is kept in place for from 
four to six weeks, and if union has occurred the patient is 
kept in bed for a few weeks longer and is then allowed to 
be about using crutches. In the majority of cases of frac- 
ture of the neck of the femur fibrous union only takes place, 
and after employing the dressing before described for six 
weeks the patient is allowed to get up and go about on 
crutches. It often happens that the subjects in whom these 
fractures occur are old and feeble, and if it is found that 
restraint in bed with the dressings here described is not well 
borne, under such circumstances they should be discarded 
and the patient should be allowed to sit up in bed with the 
limb resting on a pillow, or in a chair, the treatment of the 
local condition having to be disregarded, attention being 
given to the patient's constitutional condition. 

The application of a plaster- of Paris bandage to the leg, 
thigh and pelvis is also sometimes made use of in the treat- 
ment of fractures of the upper extremity of the femur ; 
extension should be made from the foot while the bandage 
is being applied. (Fig. 257.) In fractures of the neck of 



FRACTURES OF THE FEMUR. 



339 



the femur and of the upper part of the shaft of the bone 
the anterior wire splint of Prof. N. R. Smith is sometimes 



Fig. 257. 




Plaster-of- Paris bandage applied to thigh. (Hamilton.) 

used with advantage ; the limb being swung from the splint 
the patient is able to move in bed without causing him pain 

Fig. 258. 




^X 



J 



7 



Smith's anterior splint for fracture of the femur. 

or disturbing the fragments. (Fig. 258.) In fractures in the 
upper portion of the femur where there is marked tilting for- 



340 



FRACTURES. 



ward of the upper fragment Prof. Agnew employs extension 
made from the thigh and places the limb upon a double in- 



Fig. 259. 




Dressing of fracture of the femur with extension upon an inclined plane. 
(Agnew.) 

clined plane and maintains this position during the treatment 
of the case. (Fig. 259.) With the same object in view, in 
place of the double inclined plane a double inclined frac- 

Fig. 260. 




Double inclined fracture-box. 



ture-box may be employed, extension being made from the 
thigh by means of adhesive plaster strips applied above the 
knee, to which a weight is attached. (Fig. 260.) 

Fractures of the Shaft of the Femur. 

In the treatment of fractures of the shaft of the femur 
the dressings are applied to diminish as far as possible the 
shortening and to prevent angular or rotary displacement 



FRACTURES OF THE FEMUR. 



341 



of the fragments. In dressing these fractures the patient 
should be placed upon a fracture-bed or an ordinary bed 
with a firm hair mattress ; an extension apparatus of adhesive 
plaster is applied and extension is made by a weight attached 
to this as previously described. Lateral support is given to 
the limb by the application of two wooden splints — the outer 
or long one extending from the axilla to the foot, the inner 
or short one extending from the groin to the foot. The splints 
at their upper extremity should be about six inches in width 
and at their lower extremity about three and a half inches. 
The splints are wrapped in a splint cloth which extends 
from the foot to the groin, and after this has been placed 
under the limb the splints are fixed in their proper positions, 
the short one to the inner side, the long one to the outer 
side of the limb. Between the limb and the splints are 
interposed bran-bags ; the outer bag should be long enough 
to extend from the axilla to the foot, the inner one from the 
groin to the foot. The splints and bran-bags are held in 

Fig. 261. 




Dressing for fracture of the shaft of the femur with splints and bran-bags. 
(Ashhukst.) 



place by five or six strips of bandage passing under the 
limb and body and around the splints and bran-bags at 
intervals. The heel is saved from pressure by placing a 
wad of oakum or cotton under the tendo Achillis and after 
the splints have been brought into place the strips of ban- 



342 FRACTURES, 

dage are firmly tied to secure them and a weight of ten or 
twelve pounds is attached to the extending cord. The foot 
of the bed is raised to prevent the patient from slipping 
downward and to allow the weight of the body to act as a 
counter-extending force. After the application of the dress- 
ings the thigh should be slightly abducted. During the 
after-treatment of these fractures the surgeon should see 
that the splints and bran-bags are kept firmly in place and 
that the foot does not roll outward : this is accomplished by 
untying the strips and readjusting the bags and then bring- 
ing up the splints and securing them in position by fastening 
the strips. The extension apparatus usually does not require 
renewal during the course of treatment. The extension 
and splints are kept in place for four or six weeks and at 
this time union at the seat of fracture is usually quite firm, 
so that they may be removed, and the fracture is then sup- 
ported by moulded pasteboard splints or by the application 
of a plaster-of-Paris splint for several weeks longer, and at 
the end of eight weeks it is safe to allow the patient to be 
up and around on crutches. 

Many surgeons, in fracture of the shaft of the femur, 
prefer to use a long external sand-bag and a shorter internal 
one in place of the corresponing long and short splints and 
bran-bags, and, if care is observed to see that the sand-bags 
are kept accurately in contact with the limb and body, ex- 
cellent results may be obtained by this form of dressing. 
After considerable experience with both methods of furnish- 
ing lateral support in the dressing of fractures of the shaft 
of the femur, I am well satisfied that angular deformity is 
less likely to result where the splints and bran-bags are 
employed. 

The plaster-of-Paris dressing, including the foot, leg, 
thigh, and pelvis, is employed by some surgeons in the early 
treatment of fracture of the shaft of the femur, the limb 
being kept well extended until the plaster has thoroughly 
set. The double inclined plane and the anterior angular 
wire splint are also sometimes employed in the dressing of 
fractures of the shaft of the femur. 



FRACTURES OF THE FEMUR 



343 



Fractures of the Shaft of the Femur in Childre 



n. 



Fig. 262. 



The treatment of these fractures in young children by 
extension by a weight and pulley and lateral splints is often 
unsatisfactory on account of the difficulty in keeping the 
patient quiet upon his back, and from the soiling of the 
dressings by the feces and the urine. In children two years 
of age and over I have never found much trouble in employ- 
ing extension and. lateral support by splints and bran-bags 
or sand-bags, and in these cases I make additional fixation 
at the seat of fracture, and guard against displacement of the 
fragments by the child sitting up in bed when not watched, 
by carefully moulding external and internal pasteboard or 
felt splints to the thigh, and holding them in place by the 
turns of a bandage. I have employed this form of dressing 
even in children under two years of age 
with the most satisfactory results. 

In cases of fracture of the femur in 
children from a few months to a year or 
eighteen months of age, in whom it is 
difficult to obtain quietude, or who have 
to be moved to give them nourishment if 
they are taking the breast, the dressing 
which I have found most satisfactory 
consists in first applying a roller bandage 
from the foot to the groin, and then 
moulding to the outer half of the foot, 
leg, thigh, and also to half of the pelvis, 
a pasteboard or felt splint which is well 
padded with cotton, and held in position 
by the turns of a bandage carried from 
the foot to the pelvis and finished with 
circular turns about the pelvis. The 
splint should be so moulded as to in- 
clude a little more than one-half of the 
circumference of the thigh and leg. If this splint becomes 
soiled it is easily replaced by a fresh one, and its removal 
and renewal is much easier than that of the plaster-of-Paris 




Fracture of the fe- 
mur treated by ver- 
tical extension. 



344 FRACTURES. 

splint which is recommended by some surgeons in these 
cases. 

In young children fractures of the femur are often incom- 
plete or green-stick fractures ; and, even when complete, the 
shortening is usually not marked, as the line of fracture is apt 
to be transverse, the periosteum often not being completely 
ruptured, which tends to hold the fragments in position. 

In green-stick fractures the deformity should be reduced 
by manipulation, even if it is necessary to convert the incom- 
plete fracture into a complete one to accomplish this object. 

Mr. Bryant recommends that fractures of the femur in 
young children be treated in the vertical position ; the in- 
jured limb, together with the sound one, is flexed at a right 
angle to the pelvis and fixed with a light splint, and attached 
to a cradle or bar above the bed. (Fig. 262. ) 

If the plaster-of- Paris dressing is used, the limb should 
be first enveloped from the foot to the pelvis with a flannel 
bandage, and extension should be made while the plaster- 
of-Paris bandage is being applied and should be kept up 
until the bandage has become fixed. The plaster bandage 
should extend from the toes to the pelvis, and it is well to 
fix the hip-joint by carrying several turns of the bandage 
about the pelvis. To prevent the splint from absorbing the 
discharges and becoming offensive, the upper portion of it 
may be coated with shellac. 

The time required for union in fractures of the femur in 
children is about three weeks, and the dressings may be 
removed at this time, but the child should not be allowed to 
use the limb for several weeks after this period. 

Fractures of the Lower End of the Femur. 

The fractures met with in this portion of the femur are 
supra-condyloid fractures, or those in which one condyle is 
separated, or comminuted fractures in which both condyles 
are separated ; epiphyseal disjunctions of the lower end of 
the femur, met with in young subjects, may also be classed 
with fractures at this portion of the bone. 

The dressing of supra-condyloid fractures, if there is short- 



FRACTURES OF THE PATELLA. 345 

ening, should be similar to that employed in fractures of the 
shaft of the femur, consisting in the application of an exten- 
sion apparatus, and bran-bags and splints or sand-bags to give 
lateral support ; if, however, there is no marked shortening 
the dressing employed should be the same as that applied 
in fractures involving one or both condyles or epiphyseal 
separations. 

The dressing employed in fracture of one or both con- 
dyles or in epiphyseal disjunction of the lower end of the 
femur consists in placing the limb in a long fracture-box 
extending from the foot to the upper third of the thigh, the 
box being well padded with a soft pillow, or a well-padded 
posterior splint, or a moulded pasteboard or felt gutter may 
be employed ; if either of these dressings is employed, the 
splint or gutter should be long enough to extend from the 
lower part of the leg to the middle of the thigh. 

If there is much eifusion into the joint or soft parts, lead- 
water and laudanum should be applied over the region of 
injury for some days, until the swelling has subsided. At 
the end of two weeks it is well to place the limb in a plaster- 
of- Paris dressing, extending from the foot to the middle of 
the thigh. This dressing should be retained for four weeks, 
and at the end of this time the dressing should be removed, 
and if the union is sufficiently firm to allow the patient to 
go about on crutches, a fresh plaster-of-Paris splint should 
be applied extending from the middle of the leg to the 
middle of the thigh, or lateral splints of pasteboard may be 
substituted for the plaster dressing. 

A certain amount of permanent impairment of the joint 
motion is apt to follow fractures involving one condyle or 
both condyles of the femur. 

Fractures of the Patella. 

The dressing of fractures of the patella consists, first, in 
the application of a roller bandage from the toes to the 
upper part of the leg ; a well-padded posterior wooden splint 
long enough to extend from the middle of the leg to the 



346 



FRACTURES. 



middle of the thigh, or an Agnew splint, which is provided 
Avith pegs for the attachment of strips of adhesive plaster 
(Fig. 263) is next placed under the limb. A small compress 
of lint is next placed above the upper fragment, and a 



Fig. 263. 




Agnew's splint for fracture of the patella. 

similar compress is placed below the lower fragment ; a 
strip of adhesive plaster one and a half inches in width and 
twenty-four inches in length has its middle portion applied 
over the compress, and its ends are then brought obliquely 
downward and fastened to the splint, or to the pegs if 



Fig. 264. 




iiiiiiiiii 

Agnew's splint applied. 

Agnew's splint be used; this may be reinforced by a second 
or third strip. The object of these strips is to bring the 
upper fragment down in contact with the lower fragment. 
A strip of plaster with the ends passing in the opposite 
direction is next placed over the lower compress, and the 
ends are fastened to the splint or pegs ; this strip serves 



FRACTURES OF THE PATELLA. 347 

only to steady the lower fragment, as it cannot be drawn 
upward to meet the upper fragment by reason of the inex- 
tensibility of its ligamentous attachment. (Fig. 264.) If 
the Agnew splint is employed the strips of plaster may be 
tightened by turning the pegs to which they are fastened 
without removing the splint. 

The splint is next firmly fixed in contact with the limb 
by the turns of a roller bandage extending from the lower 
to the upper end of the splint. The limb should next be 
placed upon an inclined plane or in a long fracture-box with 
its foot elevated to relax the quadriceps femoris muscle. This 
dressing should be removed and reapplied in a few days, as 
the dressings become loose as the swelling about the seat of 
injury subsides, and after this disappears the dressings re- 
quire renewal at less frequent intervals and usually at the 
end of three weeks the splint may be removed and a plaster- 
of-Paris bandage may be applied extending from the middle 
of the leg to the middle of the thigh. At the end of six 
weeks the patient may be allowed to walk upon the limb, the 
knee-joint being fixed with a plaster-of-Paris or pasteboard 
splint - 

It is well, after the removal of the splints, for the patient 
to wear for some months a laced muslin knee-supporter, which 
gives some support to the knee-joint. 

The union in fractures of the patella is usually fibrous, 
although in rare cases bony union has occurred. 

A great variety of splints have been devised and used in 
the treatment of fractures of the patella, the main object of 
which is tu fix the knee-joint and bring the fragments as 
nearly as possible in apposition. Malgaigne's hooks or 
Levis's modification of the same are employed by some sur- 
geons to secure close apposition of the fragments. The 
method of treatment in fractures of the patella, which con- 
sists in exposing the fragments by an incision and drilling 
and suturing them with catgut or silver wire sutures, is also 
employed at the present time, the strictest antiseptic precau- 
tions being taken to prevent infection of the wound. 

In cases of rupture of the fibrous union after fracture of 
the patella, which is not an uncommon accident, the treat- 



348 



FRACTURES. 



ment of the case should be the same as that for a recent 
fracture of the patella. 

Fracture of the Bones of the Leg. 



In fractures of both bones of the leg the displacement is 
usually very marked ; when one bone only is broken, the 
sound bone, acting as a splint, prevents much deformity, 
except in case of fracture at the lower end of the fibula, 
when the foot inclines to the injured side. 

The dressing for fractures of both bones of the leg or for 
fracture of the tibia or fibula alone, except in cases where 
the lower portion of the fibula is the seat of injury, is best 
accomplished by the use of a fracture-box. (Fig. 265.) 

Fig. 265. 




Fracture- box with movable sides 



The displacement being overcome as far as possible by ex- 
tension and manipulation, the leg is placed in a fracture- 
box, which is prepared for the reception of the limb by 
having the sides let down and having a soft pillow laid in it ; 
the foot is next secured to the footboard by a loop of ban- 
dage passed around the foot, the ends being tied after 
passing through the slots in the footboard ; a pad of oakum 
or cotton is placed under the tendo Achillis to relieve the 
heel from pressure, and a similar pad is placed between 
the sole of the foot and the footboard. (Fig. 266.) The 
sides of the box are then brought up and secured by two 
or three strips of bandage tied around the box. In using 
a fracture-box in the treatment of fractures of the bones of 
the leg the surgeon should see that the foot is kept well 
down to the footboard and is at a right angle with the leg, 
that there is no eversion of the knee and that the pillow is 



FRACTURE OF THE BONES OF THE LEG. 349 

full enough to make equable pressure upon the leg when the 
sides of the box are secured, and that the heel is not sub- 
jected to undue pressure — the use of a pad of oakum or 



Fir.. 266. 




Application of the fracture -box. 

cotton under the tendo Achillis being employed to prevent 
this complication. Where there is a tendency to tilting up- 
ward of the lower end of the upper fragment the lower 
fragment can be brought in line with this by raising the 
foot by a mass of oakum or cotton placed under the tendo 
Achillis and heel and so overcoming the deformity. 

Ftg. 267. 




Plaster bandage applied to fracture of the leg. 

The subsequent dressings of the cases are conducted by 
letting down the sides of the box and correcting any dis- 
placement, if present, by adjusting the limb and pads in 
their proper position, and again bringing up the sides of the 

16 



350 



FRACTURES. 



box and securing them. At the end of two or three weeks 
the fracture-box may be removed and a plaster- of-Paris 
dressing may be applied to the limb, which will allow the 
patient more freedom of movement in bed, or permit of his 
sitting up without disturbing the fragments (Fig. 267). 

Union in fractures of the bones of the leg is usually quite 
firm in six weeks, but the patient should not be allowed to 
put his weight upon the limb in walking for at least eight 
weeks. 

If the patient is restless, and finds his position with the 
fracture-box resting upon the bed irksome, the fracture-box 
may be swung from a frame fastened over the bed (Fig. 268). 



Fig. 268. 




Fracture-box suspended. (Agnew.) 



FRACTURE OF THE BONES OF THE LEG. 35 L 

The application of a plaster-of- Paris dressing as a primary 
dressing — the ordinary plaster-of-Paris bandage or the 
Bavarian dressings being applied — in fractures of the bones 



Fig. 269. 



;'3^ 





Moulded binder's board splints for fractures of the leg. 



of the leg, is adopted by some surgeons, and, if employed, 
the case should be under constant supervision for a few days, 
so that the dressing can be removed if a dangerous amount 
of swelling takes place. Moulded splints of felt or paste- 
board are also sometimes applied in the treatment of these 
cases. (Fig. 269.) 

In patients suffering with delirium tremens, or in maniacal 
patients, the use of a fracture-box in the treatment of fractures 
of the bones of the leg is often not satisfactory on account of 
the difficulty in restraining the movements of the patient, 



352 FRACTURES. 

and the consequent displacement of the fragments. In such 
cases it is well to apply a few strips of binder's board, well 
padded with cotton, to the limb, extending above and below 
the seat of the fracture, holding them in place by a few turns 
of a roller, and then to wrap the limb and foot in a soft 
pillow and hold this in place by the turns of a roller ban- 
dage applied with moderate firmness. This dressing allows 
the patient to move the limb without serious disturbance of 
the fragments, and, after the patient recovers from his 
attack, the leg may be placed in the fracture-box. 

In fractures of the bones of the leg in young children the 
same difficulty is often experienced in keeping them quiet, 
and for this reason a fracture-box cannot be used with satis- 
faction. In dressing these cases, two lateral splints of paste- 
board, moulded to the foot and leg and well padded with cotton, 
may often be employed with the best results. The splints 
should not be wide enough to meet on the anterior or pos- 
terior surface of the leg or foot. The splints, after being 
carefully adjusted, are held in place by the turns of a roller 
bandage ; and, after these splints have been applied for two 
weeks, and all swelling has subsided at the seat of fracture, 
a plaster-of-Paris bandage may be substituted for them, 
which should be worn for three weeks ; at the expiration of 
this time union is usually firm enough to dispense with all 
dressings. 

Fractures of the Fibula. 

In fractures of the fibula, with the exception of that frac- 
ture occurring at the lower end of the bone, the deformity is 
not marked, and they are usually dressed with a fracture-box 
applied as in the dressing of fractures of both bones of the 
leg, and at the end of two weeks a plaster-of-Paris dressing 
should be applied, and the patient may be allowed to get 
out of bed and move about on crutches. The union in a 
fracture of the fibula is usually quite firm at the end of five 
weeks, and all dressings may be dispensed with at that time. 



FRACTURES OF THE FIBULA. 353 



Fracture of the Lower JSnd of the Fibula. 

This fracture usually occurs in the lower fifth of the bone 
and is often associated with a laceration of the internal 
lateral ligament of the ankle-joint or a sprain fracture of 
the internal malleolus and is usually accompanied by marked 
eversion of the foot. This fracture is commonly known as 
Pott's fracture. 

In this fracture after reducing the displacement by exten- 
sion and manipulation, the limb should be placed in a frac- 
ture-box provided with a soft pillow, the foot should be 
secured to the footboard and a pad of oakum or cotton 
should be placed under the tendo Achillis ; before bringing 
up the sides of the box and securing them two firm com- 
presses of lint or oakum should be placed in contact with 
the leg, one just above the inner malleolus, the other just 
below the outer malleolus. The sides of the box are next 
brought up and secured, and by the pressure of these com- 
presses the foot is brought into an inverted position and the 
deformity is corrected. 

The after-dressing of this fracture consists in letting 
down the sides of the box, and in inspecting the parts to 
see that the foot is kept in the proper position, and care 
should be taken to see that undue pressure is not made upon 
the skin by the compresses, which might result in ulceration ; 
this may be avoided by sponging the skin with alcohol and 
changing the positions of the compresses slightly at each 
dressing. At the expiration of ten days the fracture-box 
and compresses may be removed and the limb may be put 
up in a plaster-of- Paris dressing including the foot and leg 
up to the knee. The patient may then be allowed to go 
about on crutches and at the end of five weeks all dressings 
may be dispensed with. A certain amount of stiffness and 
even permanent impairment in the motion of the ankle- 
joint often results from these fractures. This fracture is 
also dressed by means of Dupuytreris splint, which consists 
of a straight wooden splint long enough to extend from the 
condyles of the femur to end of the toes ; this splint is 
provided with padding the thickest part of which, several 



354 



FRACTURES 



inches in thickness, should rest upon the skin just above the 
inner malleolus when the splint is applied to the inner side 
of the leg. The splint is applied to the inner surface of the 
leg with the thickest part of the pad resting upon the skin 
just above the inner malleolus, and is secured in position by 
the turns of a roller applied over the foot and at the upper 
part of the leg. After using this dressing for a few days if 
the displacement is satisfactorily corrected the splint may be 
removed and the leg may be placed in a fracture-box or in 
a plaster- of-Paris dressing. (Fig. 270.) 

Fig. 270. 




Dupuytren's splint applied. 



This splint, when applied with sufficient firmness to 
correct the displacement, is not, as a rule, a comfortable 
dressing to the patient, so that in practice the use of the 
fracture-box and compresses w r ill be found a more comfort- 
able dressing and one equally satisfactory in correcting the 
deformity. 



Fracture of the Bones of the Foot. 



Fractures of the Tarsal Bones. 



The calcaneum and astragalus are the tarsal bones most 
frequently fractured. The dressing of fractures of the cal- 
caneum after reducing the displacement, w T hich is not usually 
marked unless the posterior portion of the bone is involved, 
by manipulation, consists in placing the leg and foot in a 
fracture box, and care should be taken to see that the foot is 
kept at a right angle to the leg. When the fracture involves 
the posterior portion of the bone and there is displacement 



FRACTURES OF THE TARSAL BONES. 



355 



by the action of the muscles inserted into the fragment, the 
leg should be flexed upon the thigh and the foot should be 
extended ; this position may be maintained by applying a well- 
padded curved splint to the anterior portion of the leg and 
foot and securing it in position by a bandage, or the same 
result may be obtained by applying a band or padded collar 
around the thigh, which is made fast by a cord or strap to 
the heel of a slipper applied to the foot. (Fig. 271.) 




Apparatus for fracture of posterior portion of the calcaneum. 
(Hamilton.) 



Fractures of the astragalus, after reducing any deformity 
which is present by extension and manipulation, are dressed 
by placing the foot and leg in a fracture-box, care being 
taken to see that the foot is kept at a right angle to the leg. 
This precaution is important, as ankylosis not infrequently 
occurs after this fracture, and if the foot is in the proper 
position it is much more useful to the patient. 

As soon as the swelling, which is usually very marked 
after fracture of the calcaneum or astragalus, subsides, the 
foot and leg should be put up in a plaster-of-Paris bandage. 
The amount of tension and the inability to reduce the dis- 
placement in cases of fracture of the astragalus may be in- 
dications for excision of the fractured bone. The time re- 
quired for union in fractures of the tarsal bones is from five 
to six weeks. 



356 FRACTURES. 



Fractures of the Metatarsal Bones. 

These fractures are dressed by placing the foot upon a 
well- padded plantar splint, and using compresses to hold 
the fragments in place if there is much displacement, the 
splint and compresses being held in position by a bandage ; 
or they may be treated by placing the foot and leg in a 
fracture-box, the foot-board of the box acting as a plantar 
splint ; the plaster-of-Paris dressing may also be used in 
these cases. The time required for union in fractures of 
the metatarsal bones is from three to four weeks. 

Fractures of the Phalanges of the Toes. 

These fractures are often compound and attended with 
so much laceration of the soft parts that immediate ampu- 
tation is required ; when, however, the fractures are simple, 
or in compound fractures where amputation is not required, 
the dressing consists in applying a plantar splint of wood 
or binder's board, extending beyond the toes and securing 
it in position by the turns of a roller bandage. When a 
single toe only is broken a moulded splint of gutta-percha 
or binder's board may be applied and a portion of the splint 
should extend some distance upon the sole of the foot to fix 
the proximal joint and also to give it a firm point of fixation ; 
the moulded splint should be held in position by a narrow 
roller bandage or by strips of adhesive plaster. The time 
required for union in fractures of the phalanges of the toes 
is about three weeks. 

Dressing of Compound or Open Fractures. 

In the dressing of compound or open fractures the same 
dressings and splints which are generally used in the treat- 
ment of simple or closed fractures may be employed ; the 
wound in the soft parts requires a special dressing and 
this should be so arranged as to secure free drainage and 
promote its prompt healing. In some cases of compound 



DRESSING OF COMPOUND FRACTURES. 357 

fracture the treatment of the injures of the soft parts de- 
mands attention first, and in such cases the injury to the 
bones is for a time disregarded, care being taken to see 
that the fragments are kept quiet so as to prevent further 
damage to the soft parts until the wound is in such a con- 
dition that the proper manipulation to reduce the displace- 
ment and fix the fragments by splints and suitable dressings 
can be undertaken without interfering with the repair of 
the wound. 

In the dressing of compound or open fractures the skin 
surrounding the wound should be first carefully cleansed 
and the wound should next be thoroughly irrigated with a 
1 : 2000 bichloride solution or a 1 : 40 carbolic solution and 
any foreign bodies or loose fragments of bone should be re- 
moved, and if there is hemorrhage it should be controlled 
by securing the bleeding vessels with ligatures. The reduc- 
tion of the displacement should next be accomplished by 
making extension and by manipulation (Fig. 272); if the 

Fig. 272. 




Method of reducing a compound fracture. (Hamilton.) 



fragments project from the wound, before this can be satis- 
factorily accomplished it may be necessary to enlarge the 
wound, and to resect one or both ends of the fractured bones, 
and in some cases it may be necessary to drill the ends of 
the fragments and introduce a strong wire or catgut suture 
to hold them in their proper positions. After reduction of 

16* 



358 FRACTURES. 

the displacement the wound should again be thoroughly 
irrigated with the antiseptic solution, and after making pro- 
vision for drainage by the introduction of a drainage-tube 
or tubes, counter-openings being made to secure free drain- 
age if necessary, the dressings should be applied. 

The wound, if a small one, need not be closed with 
sutures ; but, if extensive, a few catgut, silk, or silkworm- 
gut sutures may be applied to bring the edges of the wound 
into apposition, care being taken to avoid making undue 
tension ; if the soft parts have been much lacerated or con- 
tused, it is better to introduce no sutures. A final irrigation 
of the wound through the drainage-tube is next made, and 
the wound is covered by a piece of protective, and the ordi- 
nary gauze dressing should be applied and covered by a 
number of layers of bichloride cotton, the whole dressing 
being held in position by a gauze bandage applied with 
moderate firmness. 

The reduction of the fragments and the dressing of the 
wound having been accomplished as has been described, the 
splints and dressings appropriate for a similar fracture, if it 
were a simple or closed one, are next applied. If the sur- 
geon has been able to render the wound aseptic, and has 
applied an antiseptic dressing, the compound fracture is often 
soon converted into a simple one, by the prompt healing of 
the wound, and the patient may exhibit no more constitu- 
tional disturbance than he would have with a similar simple 
or closed fracture. The re-dressing of a compound fracture 
dressed in this way need not be made for a week or ten 
days, unless there is a rise in the patient's temperature or 
the dressings become soaked with discharges from the wound, 
or they become uncomfortable to the patient by reason of 
swelling of the soft parts in the region of the wound. When 
the re-dressing of the fracture becomes necessary, the dress- 
ings are removed, and the drainage-tubes may be removed if 
no longer needed ; the wound being re-dressed with an anti- 
septic dressing, the splints are reapplied, and, after the wound 
is healed, the subsequent dressing of the fracture should be 
the same as that of a simple fracture. The time required 



DRESSING OF COMPOUND FRACTURES. 359 

for union in a compound fracture is usually much longer 
than in a corresponding simple fracture. 

Many ingenious splints have been devised for the dressing 
of special compound fractures, but these were principally 
used before the introduction of the antiseptic method of 
wound-treatment, and as the treatment of these cases has 
been much simplified by its use, they possess no special 
advantage over the ordinary splints and dressings used in 
simple fractures. 

The plaster-of- Paris dressing may be used as a primary 
dressing in compound fractures; the displacement being 
reduced and the wound being dressed with an antiseptic 

Fig. 273. 




Fenestrated plaster dressing for compound fracture of the leg. (Stimson.) 

gauze dressing, a plaster-of-Paris bandage is applied to the 
part so as to firmly fix the fragments ; the joints on either 
side of the fracture should be fixed by the bandage, and the 
parts should be held in position until the plaster has set 
firmly. After the plaster has become firm, a fenestrum 
should be made over the position of the wound, so that it 
can be inspected or dressed through this when necessary. 
The ends of a piece of stout wire, bent into a semicircle, 
may be incorporated in the turns of the plaster bandage 
above and below the position of the fenestrum, to give it 
additional strength after the removal of a portion of the 
bandage to make the fenestrum. (Fig. 273). 



360 FRACTUKES. 

If the plaster-of-Paris dressing is applied as a primary 
dressing in compound fractures the case should be carefully 
watched for a few days, and if much swelling occurs at the 
seat of fracture its removal and renewal is indicated ; pro- 
fuse discharge of serum may also soak the dressings and 
bandage so that its renewal is necessitated. Some surgeons, 
therefore, prefer to defer the application of the plaster-of- 
Paris dressing in compound fractures for a few weeks until 
the swelling has diminished and the wound is nearly or 
quite healed ; the wound being covered with an antiseptic 
dressing the plaster bandage is applied and a fenestrum is 
made over the position of the wound if required. 

Binder s- board or felt splints may also be employed in 
the dressing of compound fractures, being moulded to the 
parts after an antiseptic dressing has been applied to the 
wound, and held in position by the turns of a roller bandage. 

The principal advantage in the use of these splints is the 
ease with which they can be removed and reapplied if fre- 
quent dressings of the fracture are necessary for any reason. 
They may be used during the course of treatment, or, after 
a few weeks when the swelling has diminished at the seat of 
fracture and the wound is well advanced toward repair, they 
may be discarded and a plaster-of-Paris dressing substituted. 
In compound fractures of the bones of the leg, after reducing 
the displacement and applying an antiseptic dressing to the 
wound, I usually apply moulded binder's board splints to 
either side of the leg, including the foot, and place the leg 
in a fracture-box for additional security, and after a few 
weeks I discard the binder's-board splints and apply a 
plaster-of-Paris dressing. 

The bran dressing for compound fractures was formerly 
a popular dressing in this city, especially for compound 
fractures of the leg and thigh. It was applied by placing a 
piece of muslin or rubber cloth over the bottom and sides 
of a fracture-box and upon this was placed a layer of bran ; 
the fractured leg was next placed in the box upon the layer 
of bran, the foot was then fastened to the footboard and the 
sides of the box were brought up and secured ; bran was 
next poured into the box and firmly packed around and 



DRESSING OF COMPOUND FRACTURES. 361 

over the limb. The bran absorbed the discharges which 
escaped from the wound and at the subsequent dressings the 
soiled bran was renewed without disturbing the limb and 
fresh bran was packed about the limb. 

Sawdust which has been saturated with a solution of 
bichloride of mercury and dried may be used in the same 
manner as bran in the dressing of compound fractures and 
the former, which has been rendered antiseptic, has decided 
advantages over the bran dressing. 

Continuous irrigation of compound fractures by a warm 
antiseptic solution either of bichloride of mercury 1 : 4000 
or of carbolic acid 1 : 60 in cases in which so much contu- 
sion or laceration of the soft parts exists that the applica- 
tion of the ordinary dressings would be attended with the 
risk of gangrene, will be found a most satisfactory method 
of treatment. This dressing is applied by supporting the 
injured extremity upon a splint laid on a pillow covered by 
a rubber cloth, and a can or jar with a nozzle containing 
the solution is placed over the part and the irrigation is ac- 
complished by allowing the fluid to run continuously over 
the wound ; this irrigation may be kept up for days or weeks 
and when the vitality of the parts is assured, an antiseptic 
dressing with the ordinary splints or a plaster-of-Paris ban- 
dage may be applied. 



PART IV. 

DISLOCATIONS 



A dislocation is the displacement of the articular sur- 
faces of bones which enter into the formation of a joint. 

Dislocations may be complete, partial, simple, compound, 
and complicated, and they are also known as recent and 
old dislocations, the latter terms being used not entirely 
with reference to the length of time the displacement of 
the articular surfaces of the bones has existed. 

A complete dislocation is one in which no portions of the 
articular surfaces of the bones remain in contact with each 
other. 

A partial dislocation is one in which portions of the 
articular surfaces of the bones still remain in contact with 
each other. 

A simple dislocation is one in which there exists dis- 
placement in the relation of the articular surfaces of the 
bones with little injury to the soft parts adjacent to the joint, 
and the displaced ends of the bones do not communicate 
with the air by a wound in the soft parts. 

A compound dislocation is one in which there exists dis- 
placement of the articular surfaces of the bones which com- 
municates with the air through a wound in the soft parts. 

A complicated dislocation is one in which in addition to 
the displacement of the articular surfaces of the bones, there 
exists a fracture, or a laceration of important bloodvessels, 
nerves, or muscles in proximity to the dislocation. 

A recent dislocation is one in which the displacement of 



TREATMENT OF DISLOCATIONS. 363 

the articulating surfaces of the bones has existed for such 
a period, that time has not been afforded for inflammatory 
changes to have taken place in the articular surfaces of the 
bones or in the adjacent tissues, which would seriously inter- 
fere with their reduction. 

An old dislocation is one in which the displacement of 
the articulating surfaces of the bones has existed for some 
time, and in this variety of dislocation the displaced bones 
often form firm adhesions to the surrounding tissues. 

Treatment of Dislocations. 

The first indication in the treatment of dislocations is to 
return the displaced articular surfaces of the bones to their 
normal position and to retain them in this position by the 
use of suitable dressings The return of the articular sur- 
faces of the bones to their normal position or the reduction of 
the dislocation, is accomplished by manipulation, extension, 
and counter-extension. The reduction of dislocations should 
be attempted as soon as possible after they have occurred. 

The principal obstacles to the reduction. of dislocations are 
muscular resistance and the anatomical peculiarities of the 
joints. The former is best overcome by the use of an anaes- 
thetic given to the point where complete muscular relaxation 
is produced. The resistance offered by the changed rela- 
tions of the articular surfaces and the ligaments is to be 
overcome by the surgeon making such manipulations, 
founded upon his knowledge of the anatomy of the parts, 
as will make the ligaments, muscles, and bones assist in the 
reduction of the dislocation. 

In recent dislocations by the use of extension and manipu- 
lation, especially if an anaesthetic be employed, the reduction 
is usually accomplished without the use of much force, but 
in old dislocations, where absolute muscular shortening has 
taken place, the use of extending bands is often required, 
and in securing these bands to the limb the clove-hitch knot 
is useful. (Fig. 274.) 

The treatment of dislocations after reduction consists in 



364 DISLOCATIONS. 

placing the joint at complete rest by the application of 
suitable splints and bandages, and in treating any inflam- 
matory complications if they arise, by the application of 

Fig. 274. 




Clove-hitch knot applied. (Erichsen.) 

evaporating lotions, and in a week or two after the injured 
ligaments have been repaired, passive motion should be 
resorted to for restoring the function of the joint. 



Special Dislocations. 

Dislocations or the Vertebrae. 

Dislocations of the lumbar and dorsal vertebra?, as simple 
dislocations, are extremely rare accidents ; they are occasion- 
ally met with, but are more often associated with fractures 
of the vertebrae in these regions ; their occurrence in the 
cervical vertebrae is more common. The treatment of dis- 
locations of the vertebrae, whether complicated with fracture 
or not, consists in attempting reduction by making extension 
and counter-extension with manipulation, and by this means 
in many cases the luxations can be reduced. If, however, 
the efforts at reduction are unsuccessful, permanent extension 
should be applied by means of a weight-extension apparatus 
from both legs, and from the shoulders and head. The after- 
treatment consists in keeping the patient at rest upon his 
back in bed upon a firm mattress, and if the cervical ver- 



DISLOCATION OF THE JAW. 



S6r> 



tebne have been involved the head and neck should be sup- 
ported by short sand-bags, and in case of the vertebras 
below this point, the application of a plaster-of- Paris jacket 
may be used to give support and fixation to the parts. The 
general management of the case as regards complications is 
similar to that in cases of fracture of the vertebrae. 

Dislocations of the coccyx are reduced by manipulation 
with the finger in the rectum and external manipulation at 
the same time. The only after-treatment required is rest 
in bed for a few days, and the administration of opium to 
keep the bowels quiet. 

Dislocation of the Jaw. 

This dislocation may consist in the displacement of one 
or both condyles of the jaw from the glenoid fossae, consti- 

Fig. 275. 




Bilateral dislocation of the jaw. (Ashhubst.) 



tuting the unilateral or bilateral dislocation of the jaw ; the 
latter is the more common form of dislocation of the jaw 



3.66 DISLOCATIONS 

met with, and the deformity resulting is shown in Fig. 
275. 

The reduction of a dislocation of the lower jaw is accom- 
plished as follows : The surgeon placing his thumbs, well 
protected by strips of bandage or a towel, on the molar teeth 
or behind them presses the angles of the jaw downward while 
he elevates the chin with his fingers, and by this manipula- 

Fig. 276. 




Method of reducing dislocation of the lower jaw. (Hamilton.) 

tion the condyles of the jaw usually slip back into place 
with a snap. After reduction of the dislocation the jaw 
should be fixed for a week or ten days by the application of 
a Barton's bandage or a four-tailed sling. 

Dislocation of the Hyoid Bone. 

A few cases of dislocations of the hyoid bone have been 
recorded ; the treatment consists in throwing back the head 
as far as possible, to place the muscles of the neck upon the 
stretch, depressing the lower jaw and pressing the luxated 
bone into position. 

Dislocations of the Ribs. 

The ribs may be dislocated at their vertebral articulations, 
or at the junction with their costal cartilages. The treatment 
of these dislocations consists in reducing the displacements 
by manipulation and pressure and then in fixing the chest to 



DISLOCATIONS OV THE PELVIS. 367 

secure immobility of the ribs by strapping the affected side 
with strips of adhesive plaster, the same dressing being 
applied as in case of fracture of the ribs, the dressings being 
retained for three or four weeks. 



Dislocation of the Sternum. 

Dislocation or diastasis of the sternum may occur at the 
junction of the manubrium and gladiolus or at the junction 
of the ensiform cartilage and gladiolus. The reduction is 
effected by extension of the chest by bending the dorsal 
spine over a firm cushion placed under the back and by 
pressure upon the projecting bone; when the displaced bone 
has been reduced, a compress should be placed over the 
seat of injury and held in place by broad strips of adhesive 
plaster or by a bandage to keep the parts at rest. The 
dressing should be retained for three or four weeks. 

In the few examples of dislocations of the ensiform car- 
tilage which have been reported, the displacement of the 
cartilage has in some cases given rise to persistent vomiting, 
which was relieved by reduction of the displacement ; it is, 
however, almost impossible to keep the fragment in place 
after reduction, and the vomiting gradually disappears after 
a time in these cases where it was impossible to keep the 
cartilage in its normal position. 

Dislocations of the Pelvis. 

Dislocations or diastasis of the bones of the pelvis may 
occur at the pubic or sacro-iliac symphyses. 

These are generally serious injuries, as they are apt to 
be complicated by lesions of the pelvic viscera. 

The reduction of these dislocations is effected by pressure 
and manipulation, and after reduction the parts should be 
supported by a compress held in place by a stout binder or 
by broad strips of adhesive plaster, the patient being kept 
quiet in bed, and the pelvis being supported by means of 



368 



DISLOCATIONS 



sand-bags. The dressings should be retained for from four 
to six weeks. 



Dislocations of the Clavicle. 

Dislocations of the clavicle may occur either at the 
sternal or acromial end, and the latter injury some writers 
describe as a dislocation of the scapula, following the gen- 
eral rule that the distal bone is the one dislocated. 

Dislocations of the sternal end of the clavicle may occur 
in a forward, backward, or upward direction, and the dis- 
placement is generally well marked. (Fig. 277.) The re- 
duction of this dislocation is effected by placing the knee 
against the spine and drawing the shoulders outward and 
backward and pressing the displaced end of the clavicle 



Fig. 277. 



Fig. 278. 





Dislocation of sternal end of clavicle 
forward. (Bryant.) 



Dislocation of clavicle at acromial 
end. (Bryant.) 



into place. The reduction is generally easy, but it is often 
difficult to keep the end of the bone in its proper position. 
To accomplish this, a compress should be placed over the 
end of the bone, and this should be secured in place by 
broad strips of adhesive plaster ; the shoulders should be 
brought well backward and secured by a posterior figure-of- 
eight bandage of the chest, and the arm of the injured side 



DISLOCATIONS OF THE SCAPULA. 369 

should be fastened to the side of the chest by spiral turns 
of a bandage. In some cases, in addition to the compress 
over the end of the bone, securing the arm of the injured 
side in the Velpeau position will be found all that is 
necessary to retain the bone in position. 

Dislocation of the acromial end of the clavicle may be 
upward, downward, or backward. (Fig. 278.) The reduc- 
tion is effected by manipulation of the arm and scapula and 
by pressure over the displaced end of the clavicle ; the dis- 
placement is usually reduced without much trouble, but it 
is often a matter of difficulty to keep the end of the bone 
in its proper place. 

The dressing consists in placing a compress over the 
acromial end of the clavicle and holding it in place by 
broad strips of adhesive plaster; the arm should at the 
same time be fixed in the Velpeau position. These dress- 
ings after reduction of dislocations of the clavicle should be 
kept in place for at least three weeks. Although in many 
cases a certain amount of deformity persists, the disability 
resulting from the injury is not often marked. 



Dislocations of the Scapula. 

Dislocation of the acromion processes of the scapula 
from the outer end of the clavicle, which has been described 
under dislocation of the acromial end of the clavicle, is 
classed by some writers as a scapular dislocation. 

Dislocation or projection of the inferior angle of the 
scapula, due to its escape from under the latissimus dorsi 
muscle or relaxation of this muscle and of the serratus 
magnus, is sometimes described as a dislocation of the in- 
ferior angle of the scapula. The reduction of this deformity 
consists in the employment of manipulation and pressure to 
overcome the displacement, and the use of a compress held 
in place by broad strips of adhesive plaster to secure the 
bone in its proper position. 



370 



DISLOCATIONS. 



Dislocations op the Shoulder. 

The head of the humerus may be dislocated downward, 
forward, or backward. 

Subglenoid or downward dislocation of the head of the 
humerus is that variety of dislocation in which the head of 
the bone rests in the axilla. (Fig. 279.) 

Fig. 279. 




Subglenoid dislocation of the shoulder. (Stimson.) 



Subcoracoid or forward dislocation of the head, of the 
humerus is that variety of dislocation in which the head of 
the humerus rests beneath the coracoid process of the scapula. 
(Fig. 280.) 

Subclavicular dislocation of the head of the humerus may 
be considered an aggravated form of the latter variety of 



DISLOCATIONS OF THE SHOULDER. 371 

dislocation : the head of the humerus in this variety of dis- 
location rests beneath the clavicle. 

Fig. 280. 



Subcoracoid dislocation of the shoulder. (Stimsox.) 

Subspinous or backward dislocation of tlie head of the hu- 
meru8 is that variety of dislocation in which the head of the 
humerus rests beneath the spine of the scapula. (Fig. 281.) 

The reduction of dislocations of the humerus is effected 
by manipulation, by extension and counter-extension, and 
by a combination of these methods. 

Manipulation in the reduction of subglenoid dislocation 
of the humerus is practised by first flexing the forearm upon 
the arm to relax the long head of the biceps muscle; the 
elbow is next seized and abducted so as to bring it to the 
side of the patient's head, thus relaxing the deltoid and 
supra-spinous muscles ; the surgeon or an assistant next 



372 



DISLOCATIONS, 



places his hand upon the head of the humerus in the axilla, 
and, as the arm is drawn outward to a right angle with the 



Fig. 281. 




Subspinous dislocation of the head of the humerus. (Erichsek.) 



body by the other hand, he pushes the head of the bone into 
the glenoid cavity. 

In the reduction of subglenoid and subclavicular disloca- 
tions the manipulation is the same except that the arm is to 
be rotated outward before being carried downward. 

In the reduction of subspinous dislocations after the arm 
has been abducted it should be rotated inward and direct 
pressure should be made upon the head of the bone as the 
arm is adducted. Reduction may also be effected by exten- 
sion and counter-extension as in Cooper's method, where 
extension is made from the arm downward and counter- 
extension is made by the heel in the axilla. (Fig. 282.) 

Reduction may also be accomplished by extension made 
upward, as in Mothe's method, the scapula being fixed by 
the foot or hand placed over the acromion process. (Fig. 283.) 

After reduction of dislocations of the head of the humerus 
the arm should be bound to the side of the body by the 



DISLOCATIONS OF THE SHOULDER. 
Fig. 282. 



373 




Reduction of shoulder by heel in the axilla. (Erichsen.) 
Fig. 283. 





WJ 


i 

k't.-. 1 - 


.:> 


_^__- — 























Reduction of shoulder by extension upward. 

turns of a spiral bandage of the chest, or should be held 
against the side by the application of a Velpeau bandage 
(Fig. 46, p. 55); this dressing should be removed at in- 

17 



374 



DISLOCATIONS. 



tervals of a few days, and after ten days or two weeks all 
dressings should be dispensed with, passive motion should 
be employed and the patient should be allowed to move 
the arm. • 

Dislocations of the Elbow. 

Dislocation of the Bones of the Forearm. 

Dislocations of the bones of the forearm at the elbow may 
either be backward, forward, or lateral. The backward dis- 
location is the most common form. (Fig. 284.) 



Fig. 284. 




Dislocation of both bones of the forearm backward. (Liston.) 

The reduction of backward dislocations is effected by 
making traction upon the forearm and at the same time 
making pressure upon the lower end of the humerus as the 
forearm is flexed upon the arm. 

Or the reduction may be accomplished by bending the 
arm slowly and forcibly over the knee placed upon the inner 
surface of the elbow so as to press upon the radius and ulna, 
separating them from the humerus and freeing the coronoid 
process from its abnormal position. (Fig. 285.) 

Lateral dislocations of the bones of the forearm at the 
elbow are reduced by making extension from the forearm, 
and at the same time making direct pressure on the dis- 
placed bones and counter-pressure on the lower end of the 
humerus. 



DISLOCATIONS OF THE ELBOW. 



375 



Forward dislocations of the bones of the forearm at the 
elbow are reduced by making forced flexion at the elbow, 
together with extension or counter-extension, or by making 



Fig. 2S5. 




Reduction with the knee in the bend of the elbow. (Hamilton.) 
Fig. 286. 




Dressing after reduction of dislocations of the elbow. 



376 



DISLOCATIONS. 



forced extension of the "forearm at the elbow, pressing the 
humerus backward and suddenly flexing the forearm. 

The dressing, after the reduction of dislocations at the 
elbow, consists in the application of a well-padded anterior 



Fig. 287. 




Dislocation of head of the radius forward. (Liston.) 



right- or slightly obtuse- angled splint, to keep the forearm 
in a flexed position — the dressing being practically the same 
as that for fractures of the lower end of the humerus, with 
an anterior angular splint (Fig. 286). This dressing should 
be retained for two or three weeks, being removed at inter- 
vals of several days ; after the removal of the splint, passive 



DISLOCATIONS AT THE WRIST. 377 

motion should be practised, to prevent stiffness of the elbow- 
joint. 

Dislocation of the Head of the Radius. 

The head of the radius may be displaced forward, outward, 
or backward, the forward dislocation being the most frequent. 
(Fig. 287.) The reduction of these dislocations is effected by 
making extension from the forearm and counter-extension 
from the lower end of the humerus, and at the same time the 
head of the bone is pressed into its proper position. The 
dressing after reduction of the displacement consists in the 
application of a compress over the head of the bone, and the 
arm and forearm should be placed upon a well-padded ante- 
rior angular splint, which is secured by a roller bandage. 
The dressing is similar to that employed in fractures of the 
lower end of the humerus, in which an anterior angular splint 
is employed (Fig. 242, page 325). Difficulty is sometimes 
experienced in keeping the head of the bone in position after 
reduction, so that the use of the compress in addition to the 
use of the splint is often required. The arm should be kept 
upon the splint for three weeks, being redressed at intervals. 

Dislocation of the Upper End of the Ulna. 

The upper end of the ulna may be displaced backward, 
the olecranon projecting behind the condyles of the humerus, 
while the head of the radius occupies its normal position. 
The reduction of this displacement is effected in the same 
manner as that of both bones of the forearm backward, and 
the dressing after reduction is similar to that employed when 
both bones have been displaced. 

Dislocations at the Wrist. 

The lower end of the ulna may be dislocated from the 
radius forward, backward, or inward. The reduction of 
these displacements is effected by fixing the radius and push- 
ing the ulna back into place. The dressing after reduction 



378 



DISLOCATIONS. 



consists in placing the wrist-joint at rest by the application 
of well-padded anterior and posterior straight splints. The 
splints should be retained for three or four weeks, dressings 
being made at intervals of two or three days. 

Dislocations of the carpus upon the bones of the forearm 
may be forward (Fig. 288), or backward (Fig. 289). The 



Fig. 288. 



Fig. 289. 





Dislocation of the carpus forward. 
(Hamilton.) 



Dislocation of the carpus backward. 
(Hamilton.) 



reduction in either variety of displacement is effected by 
extension from the hand and by pressure. After reduction 
of the displacement, which does not tend to recur, the hand 
and forearm should be placed upon a well-padded straight 
splint applied to the palmar surface of the hand and fore- 
arm. The splint should be retained for ten days or two 
weeks. 

Dislocations of the Bones of the Carpus. 



The displacement of the individual bones of the carpus 
occasionally takes place, the os magnum, the semilunars 
and pisiform being the bones most usually displaced, although 
other bones of the carpus are sometimes dislocated. Reduc- 



DISLOCATIONS OF THE FINGERS. 379 

tion is effected by means of extension and pressure, and the 
part should afterward be dressed with a palmar splint and 
compresses. 

Dislocations of the Metacarpal Boxes. 

The metacarpal bones may be dislocated upon the carpus ; 
the bones most commonly displaced are those of the thumb, 
and of the index and middle fingers ; the latter are usually 
displaced backward, while the metacarpal bone of the thumb 
may go either backward or forward. 

Reduction is effected by extension and pressure. The 
dressing after reduction consists in the application of a 
palmar splint to the hand and forearm and a compress over 
the displaced bone. The dressings should be retained for 
two weeks. 

Dislocations of the Fingers. 

Dislocations of the phalanges of the hand usually take 
place at the metacarpophalangeal junction, but sometimes 
occur at the intra-phalangeal joints. The reduction is 
usually easily effected by extension (Fig. 290), or by push- 

Fig. 290. 




Backward dislocation of phalanx Reduction by extension. (Hamilton* ) 

ing the phalanx back until it stands perpendicularly upon 
the metacarpal bone, when by strong pressure upon its 
base, from behind forward, it is readily carried by flexion 
into its natural position. 



380 



DISLOCATIONS. 



Where difficulty is experienced in making extension in 
the reduction of these dislocations, the ingenious apparatus 
of the late Dr. Levis (Fig. 291), or the " Indian puzzle " 
apparatus (Fig. 292) may be employed with success. 



Fig. 291. 




Levis's apparatus for dislocation of the phalanges applied. 
Fig. 292. 




Extension by Indian puzzle. (Bryant.) 

In dislocations of the proximal phalanx of the thumb 
backward (Fig. 293), great difficulty in reduction is often 

Fig. 293. 




Dislocation of proximal phalanx of thumb backward. (Farabeuf.) 

experienced from the head of the metacarpal bone slipping 
between the two heads of the short flexor muscle, or be- 



DISLOCATIONS OF THE HIT 



381 



tween the lateral ligaments. The interposition of the exter- 
nal sesamoid bone is considered by some surgeons to be the 
cause of difficulty in the reduction of this displacement. 

In this dislocation reduction is effected by firmly press- 
ing the metacarpal bone of the thumb strongly toward the 
palm of the hand to relax the two portions of the short 
flexor muscle. The thumb is next extended upon the wrist 
until its tip points to the elbow. An assistant now places 
his finger behind the proximal phalanx to prevent its slip- 
ping backward and by bringing the thumb down to the 
flexed position the bone slips into place. It sometimes 
happens that all efforts at reduction fail, and in such cases 



Fig. 294. 



Fig. 295. 





Backward and upward 
dislocation of femur. 
(Cooper.) 



Backward dislocation of 
femur. (Cooper.) 



382 



DISLOCATIONS 



it may be necessary to divide one head of the short flexor 
muscle subcutaneously or through an open wound, before 
the displacement can be relieved. 

The dressing of dislocations of the phalanges after reduc- 
tion consists in the application of splints of wood, or 
moulded splints of binder's board or gutta-percha to fix the 
joint, which should be retained for ten days or two weeks. 

Dislocations of the Hip. 



The head of the femur is most frequently dislocated back- 
ward, downward or upward, although it may assume other 
positions in exceptional cases. 

Posterior or backward dislocations of the head of the 
femur are either backward and upward, and are described as 
iliac or dorsal, the bone resting upon the dorsum of the 
ilium (Fig. 294). Or the dislocation may be backward, the 
head of the bone resting upon the ichiatic notch ; these are 
known as ischiatic dislocations or 
dislocations of the femur dorsal 
below the tendon (of the obturator 
internus), according to Bigelow 
(Fig. 295). 

The reduction of the posterior 
dislocations of the femur can gen- 
erally be effected by manipulation. 
The patient being anaesthetized and 
placed upon his back, the surgeon 
grasps the leg at the ankle and 
knee, flexes the leg upon the thigh, 
and the thigh upon the pelvis ; he 
then abducts the limb and rotates 
it outward, bringing it in a broad 
sweep across the abdomen, and by 
bringing it down to its natural 
position the head of the bone will slip into the acetabulum 
(Fig. 296). 

Downward Dislocation of the Head of the Femur, or 
Downward arid Forward Dislocation. — In this variety of 




Reduction of backward dis- 
location of femur.(BiGELOW.) 



DISLOCATIONS OF THE HIP. 



383 



dislocation the head of the bone rests upon the thyroid 
foramen ; this form of displacement is sometimes spoken of 
as a thyroid dislocation. (Fig. 297.) 

The reduction of downward and forward dislocations of 
the head of the femur is effected by flexing the leg and 
thigh and bringing the limb into a position of abduction ; it 
is then adducted and rotated inward in a broad sweep across 
the abdomen and brought down to its natural position, and 
the head of the bone slips into the acetabulum. (Fig. 
298.) 

Fig. 297. Fig. 298. 





Downward and forward dislocation 
of femur. (Cooper.) 



Reduction of downward and for 
ward dislocation of he femur 
(Bigelow.) 



In making these manipulations the head of the bone 
sometimes slips back upon the dorsum of the ilium, con- 
verting the downward dislocation into a posterior one if 



384 



DISLOCATIONS 



Upivard Dislocation, 
Upward, of the Head 



this accident occurs the displacement should be remedied by 
making the manipulation appropriate for the reduction of 
the latter dislocation. 

or the Dislocation Forward and 
of the Femur. — In this variety of 
dislocation the head of the bone 
rests upon the pubis ; this form of 
displacement is also spoken of as a 
pubic dislocation. (Fig. 299.) 

The reduction of forward and 
upward dislocations of the head of 
the femur is effected by much the 
same manipulation as is employed 
in the reduction of downward and 
forward dislocations, except that 
in the pubic dislocation the flexed 
limb should be carried across the 
sound thigh at a higher point. 
The thigh being flexed the head 
of the bone is drawn down from 
the pubis; it is then semi-abducted 
and rotated inward to disengage 
the bone completely. While ro- 
tating inward and drawing on the 
thigh the knee should be carried 
inward and downward to its place 
by the side of its fellow, and the 
head of the bone will usually slip 
into the acetabulum. 

As before stated various anoma- 
lous displacements of the head of 
the femur occasionally occur ; the 
head of the bone may pass directly 
upward, or downward between the 
sciatic notch and thyroid foramen, or downward and back- 
ward on the body of the ischium, or downward and back- 
ward into the lesser sciatic notch, or downward, inward, and 
forward into the perineum. These anomalous displacements 




Forward and upward dis 
location of the femur 

(CuOPER.) 



DISLOCATIONS OF THE PATELLA. 



385 



usually occur where there has been extensive laceration of 
the capsular and Y-ligaments. 

The dressing of cases, after reduction of dislocations of 
the head of the femur, consists in keeping the patient at rest 
in bed upon his back, and the limb should be kept at rest 
by sand-bags applied to either side of the limb, or the knees 
should be tied together. 

The patient should be kept at rest for two or three weeks, 
and at the end of this time may be allowed to get out of 
bed and go about on crutches. 



Fig. 300. 



Dislocations of the Patella. 

The patella may be dislocated outward, inward, or upward, 
or it may be rotated upon its own axis. The outward dis- 
location is the displacement most 
usually seen. (Fig. 300.) 

Upward dislocation of the 
patella can only result from 
laceration of the ligamentum 
patellae, and the treatment in 
such cases is similar to that for 
fracture of the patella. 

The reduction of dislocations 
of the patella is effected by ex- 
tending the leg upon the thigh, 
and flexing the thigh upon the 
pelvis to relax the quadriceps 
femoris muscle, when the patella 
can usually be forced back into 
place ; in some cases alternate 
flexion and extension of the leg 
will accomplish the same result. 

The dressing after reduction 
of the displacement consists in 
the application of a posterior 
straight splint or a moulded 
binder's-board or felt splint to 
keep the joint at rest: the splint should be worn for a week 
or ten days. 




Outward dislocation of the 
patella. (Duplay.) 



386 dislocations. 

Dislocations of the Knee. 

The head of the tibia may be dislocated forward, back- 
ward, or laterally ; the latter dislocations are always incom- 
plete, forward dislocation being the variety of displacement 
most commonly met with. (Fig. 301.) 




JSxfl condyle of femur 
Forward dislocation of the knee. (Bryant.) 

The reduction of dislocations of the knee is effected by 
extension and counter-extension with forced flexion of the 
knee with pressure, aided by rocking movements. The 
treatment of cases of dislocation of the knee after reduction 
consists in fixing the knee-joint by the application of a 
straight posterior splint or a moulded splint of binder's 
board. As there is usually marked swelling following these 
injuries from violence to the joint-structures, the application 
of evaporating lotions for a few days will be found useful. 
As soon as the swelling has subsided the joint should be put 
up in a plaster- of-Par is dressing and this should be retained 
for four weeks. 

Dislocation of the Semilunar Cartilages. 

The displacement here consists in the slipping forward or 
backward and wedging of the semilunar cartilages between 
the femoral condyles and the tibia. 

Reduction of the displaced cartilages can usually be 
effected by hyper-flexion of the knee followed by sudden 
full extension, or by alternately flexing and extending the 



DISLOCATIONS OF THE ANKLE. 387 

joint. Excision of the displaced cartilages is sometimes 
required in cases in which they cannot be reduced by man- 
ipulation. 

The dressing of these cases after reduction of the dis- 
placed cartilages consists in the application of a posterior 
straight splint or a plaster-of-Paris dressing to fix the knee- 
joint ; the splint should be worn for three or four weeks, and 
if there is a tendency to redisplacement the patient should 
wear a knee-cap of leather or muslin to partially fix the 
joint, with compresses so arranged as to make pressure 
upon the edge of the joint. 

Dislocation of the Fibula. 

Dislocations of the fibula may occur at either of its ex- 
tremities, and the direction of the displacement may be 
forward, backward, or upward, dislocation of the head or 
upper extremity of the fibula being the most common, 
although all are rare forms of displacement. 

The reduction of dislocations of the head of the fibula is 
effected by flexing the leg upon the thigh and making direct 
pressure and extension. Dislocations of the lower extremity 
of the fibula are reduced by manipulation and pressure. 
The dressing of cases after reduction of dislocations of the 
fibula consists in the application of a compress and moulded 
binder's board splint, and the dressing should be retained for 
three or four weeks. 

Dislocations of the Ankle. 

Dislocation of the foot upon the bones of the leg results 
from the separation of the articular surface of the astragalus 
from that of the tibia and fibula, and the displacement may 
be forward^ hackivard (Fig. 302), or lateral (Fig. 303), the 
latter variety being often associated with fracture of the 
malleoli. 

The reduction of dislocations of the ankle is effected by 
traction, combined with flexion and rotation of the ankle- 



388 



DISLOCATIONS. 



joint, the leg being first flexed upon the thigh to relax the 
tendo Achillis, and in some cases the subcutaneous division 
of this tendon is required before the reduction can be satis- 
factorily accomplished. 



Fig. 302. 



Fig. 303. 





Dislocation of foot backward. 
(Bryant.) 



Dislocation of foot inward. 
(Bryant.) 



The dressing of dislocations of the ankle after reduction 
consists in the application of a fracture-box, or of pasteboard 
splints to fix the ankle, care being taken to see that the foot 
is fixed at a right angle to the leg, and in the application of 
evaporating lotions for a few days ; after the swelling has 
subsided, a plaster-of-Paris dressing should be applied and 
retained for three or four weeks. 



Dislocations of the Tarsal Bones. 



The astragalus may be dislocated from the bones of the 
leg and from the other tarsal bones, being thrust forward, 
backward, outward (Fig. 304), or inward. The reduction of 
dislocations of the astragalus outward is effected by first flex- 



DISLOCATIONS OF THE TARSAL BONES. 389 



Fio. 304. 



ing the leg upon the thigh and making extension from the 
foot and rotating it at the same time, direct pressure being 
made upon the displaced bone ; 
in some cases subcutaneous sec- 
tion of the tendo Achillis has 
assisted materially in the reduc- 
tion of the displaced bone. 
Backivard dislocation of the 
astragalus is usually irreduci- 
ble, the patient, however, in 
many cases recovers with a 
useful foot. In cases of irre- 
ducible dislocations of the as- 
tragalus, excision of the as- 
tragalus may ultimately be re- 
quired. 

After the reduction of dis- 
locations of the astragalus, the 
foot and leg should be put at 
rest in a fracture-box, or by 
means of moulded splints of 
pasteboard or felt ; evaporat- 
ing lotions should also be em- 
ployed to the region of the in- 
jury for a few days, and when 
the swelling has subsided, a 
plaster-of-Paris dressing should be applied and retained for 
three or four weeks. 

Dislocations of the calcaneum and scaphoid upon the 
astragalus, or of the calcaneum upon the astragalus and 
cuboid, or upon the astragalus alone ; of the scaphoid and 
cuboid upon the calcis and astragalus ; or of the cuboid, 
scaphoid, or cuneiform bones, are occasionally met with. 

Their reduction is effected by traction and direct pressure, 
and, after this has been accomplished, the parts should be 
put at rest by the application of a splint and compresses. 




Dislocation of astragalus out- 
ward. (Hamilton.) 



390 



DISLOCATIONS. 



Dislocations of the Metatarsal Bones and Pha- 
langes op the Toes. 

These dislocations usually result from crushing forces 
which destroy the vitality of the soft parts so completely 
that amputation is required. Their reduction in cases of 
simple or uncomplicated dislocations is effected by traction, 
manipulation, and pressure. After reduction of the dis- 
placement, the parts should be kept in position by the appli- 
cation of splints and compresses. 

Old Dislocations'. 

The reduction of old dislocations is attended with more 
difficulty and danger than that of recent dislocations, due to 
the permanent contraction and structural changes which 



Fig. 305. 




Reduction of old dislocation of the femur by pulleys. (Cooper.) 

occur in the muscles, and to the abnormal adhesions which 
form between the displaced bone and the parts with which it 
is in contact. The reduction of old dislocations can usually 
be accomplished by the manipulations appropriate for recent 
dislocations of the same variety, but occasionally the use of 
more forcible extension is required, which is made by bands 



OLD DISLOCATIONS. 



391 



and pulleys (Fig. 305), or by vertical extension (Fig. 306). 
The first step in the reduction of old dislocations consists in 
thoroughly breaking up the adhesions which have been 
formed between the displaced bone and the surrounding tis- 
sues ; this has, in some cases, resulted in the laceration of 



Fig. 306. 




Reduction of old dislocation of hip by vertical extension. (Bigelow.) 

muscles, nerves, and bloodvessels, and in the fracture of the 
displaced bones or neighboring bones, so that the manipula- 
tions should be made with the least force that will accom- 
plish the object desired. After the reduction of old 
dislocations, difficulty is sometimes experienced in main- 
taining the bone in its proper place, due to the changes 
which have occurred in the articular surfaces. 



392 dislocations. 

Compound Dislocations. 

These are always grave injuries, and amputation or 
excision is often required. When, however, operative 
measures are not required, the reduction is effected in the 
same manner as in simple dislocations of corresponding 
parts, the greatest care being taken to render the wound 
aseptic, and to keep it in this condition by the application 
of a full antiseptic dressing. 

Complicated Dislocations. 

In dislocations complicated by fracture near the seat of 
displacement, the displaced bone should, if possible, be first 
reduced, and this in many cases is a matter of much diffi- 
culty as the fracture prevents the surgeon from using lever- 
age otherwise present, in the reduction, and he has often to 
depend entirely upon pressure and manipulation to restore 
the displacement. 

After reduction of the dislocation the fracture should be 
reduced and dressed. 

Dislocation complicated by rupture of the main artery of 
the limb may require, after reduction of the displacement, 
exposure and ligation of the vessel or amputation of the 
limb. Rupture of an important nerve trunk complicating 
a dislocation may call for subsequent exposure and suturing 
of the divided nerve. 

Spontaneous Pathological and Congenital 
Dislocations. 

In the treatment of these varieties of dislocations after 
the reduction of the displacement by manipulation and pres- 
sure much difficulty is often experienced in maintaining the 
reduction. To effect the latter object the use of splints and 
bandages is employed and also the use of many ingenious 
forms of apparatus adapted to particular dislocations. 

Tenotomy or myotomy are often required to prevent 
recurrence of the deformity, and continuous extension is 
also of much value in the treatment of these displacements. 






PART V. 

LIGATION OF ARTERIES 



In the application of a ligature to an artery in its con- 
tinuity the surgeon should make his incision in the line 
which corresponds to the general course of the vessel and 
he should be thoroughly familiar with the anatomy and with 
the surgical landmarks of the part. A portion of the 
vessel, when possible, should be selected for the application 
of the ligature half an inch or an inch from any large col- 
lateral branch. The position of the incision being selected 
the surgeon steadies the skin with two fingers and makes an 
incision of the required length through it with a scalpel ; 
the superficial fascia is next picked up on a director, any 
large superficial veins which come into view being displaced, 
and divided to an equal length with the incision in the skin ; 
the deep fascia being exposed it should be nicked and 
divided upon a director ; the inter-muscular space or the edge 
of the muscle or muscles which are the guide to the vessel 
should next be sought for, small vessels coming from the 
main vessel through these spaces will often serve as valuable 
guides to the position of the vessel. The surgeon next 
separates the tissues with the director, handle of the knife, or 
the finger until the sheath of the vessel is exposed ; this is 
recognized by its communicated pulsation and by the absence 
of the smooth shining surface and pinkish-white color which 
the surface of the artery presents. The sheath of the artery 
should be picked up with forceps and nicked with the point 
of the knife applied flatwise ; the incision into the sheath 
should be very limited, only large enough to allow the 



391 



LIGATION OF ARTERIES. 



aneurism needle to pass through it around the vessel ; ex- 
tensive dissections or separations of the sheath from the 
vessel should be avoided as the nutrition of the artery at the 
point of ligature may thus be impaired and sloughing and 
secondary hemorrhage may result. A distinct sheath is 
found only about the main arterial trunks, which is replaced 
in the smaller arteries by a layer of loose cellular tissue. 
The wall of the artery being exposed an aneurism needle is 



Fig. 307. 



Fig. 308. 





Opening sheath. Passing ligature around the 
vessel. Tying artery. (Bryant.) 



Aneurism needle. 



passed around the vessel, threaded with a catgut ligature, and 
withdrawn ; the needle may be threaded before being passed, 
in which case the ligature is grasped with forceps and drawn 
through while the needle is withdrawn. The best material 
for ligatures is carefully prepared chromicized catgut. The 
needle should be passed away from important structures 
such as accompanying veins and nerves. 

Before the ligature is tied the surgeon should satisfy him- 
self that the ligature when tied will control the circulation 



LIGATION OF INNOMINATE ARTERY. 395 

in the vessel below its point of application, by placing the 
tip of his finger upon the vessel and drawing upon the ends 
of the ligature so as to occlude the vessel at the point of 
application. Being satisfied as to this point the ligature is 
tied with a reef-knot, or a surgeon 's-knot and reef-knot com- 
bined. 

Some authorities recommend the application of two liga- 
tures a short distance apart in the ligation of vessels in their 
continuity, and a division of the vessel between them, so that 
both ends can retract into the cellular sheath. 

The ends of the ligature are cut short in the wound, 
which is irrigated and drained if necessary, and is closed by 
the application of a few sutures, and an antiseptic dressing 
is applied. 

Ligation of Special Arteries 
Ligation of the Innominate Artery. 

The innominate artery lies immediately behind the sterno- 
clavicular articulation, and is in relation in front with the 
innominate veins and pneumogastric nerve, on the inner 
side with the trachea, on the outer side and behind with the 
pleura. 

Incision. — A Y-shaped incision, each branch of which is 
two and a half or three inches in length, one of which lies 
over the anterior edge of the sterno-cleido-mastoid muscle, 
and the other parallel to and a little above the clavicle. 
(Fig. 309, ^4.) The incisions are carried down to the super- 
ficial fascia and a flap is dissected up. If the anterior 
jugular vein is met with it should be displaced. The sternal 
and clavicular attachments of the sterno-cleido-mastoid are 
next divided upon a director half an inch above the bone. 
The sterno- thyroid and sterno-hyoid muscles and the middle 
cervical fascia are next exposed, covered by the thyroid veins. 
The outer fibres of the sterno-hyoid and sterno-thyroid 
muscles are next divided, the thyroid vein being held aside, 
when upon tearing through the fascia with a director the 
common carotid artery is exposed and traced down to the 



396 



LIGATION OF ARTERIES. 



innominate artery; the innominate veins are pressed against 
the sternum with the finger and the artery is separated from 
its sheath about half an inch below its bifurcation, and the 

Fig. 309. 




Line of incision for — A, innominate artery ; B, right subclavian artery ; 
C, left subclavian artery ; D, vertebral or inferior thyroid artery ; E, axil- 
lary artery below clavicle. (Stimson.) 

aneurism needle is passed around the vessel from the outer 
side so as to avoid the vein, pneumogastric nerve, and 
pleura. 

Ligation of the Subclavian Artery. 



This artery, may be tied at three points ; in its first por- 
tion, between the trachea and scaleni muscles ; in its second 
portion, behind the scaleni muscles, and in its third portion 
external to the scaleni muscles. 

The left subclavian artery in its first portion is larger and 
more vertical in its direction than the right subclavian and 
is situated more posteriorly ; from the difficulty in exposing 



LIGATION OF SUBCLAVIAN ARTERY. 397 

this portion, and from the possibility of injuring the thoracic 
duct, the ligation of this artery in its first portion has been 
seldom attempted. 

Incision for the first portion of the subclavian artery is 
the same as that for the innominate (Fig. 309, A), and the 
ligature is passed from the outer side, the pneumogastric 
and phrenic nerves being pressed inward toward the carotid 
artery. 

The right or left subclavian arteries are also seldom tied 
in their second portions, that is behind the scaleni muscles, 
but are frequently tied in their third portions, that is ex- 
ternal to the scaleni muscles. 



Fig. 310. 




Ligation of subclavian and lingual arteries. (Bryant.) 
18 



398 LIGATION OF ARTERIES 

Incision for the second portion of the subclavian artery 
begins an inch external to the sterno-clavicular articulation 
half an inch above and parallel to the clavicle, and is three or 
four inches in length. (Fig. 309, B or 0.) The steps of the 
operation are the same as for ligation of the third portion, 
and when the scalenus anticus muscle has been exposed it is 
divided upon a director ; the phrenic nerve which lies upon 
its anterior aspect is to be avoided. 

Incision for the third portion of the subclavian artery is 
the same as for the second portion. (Fig. 309, B or C.) 
The skin and platysma being divided, the jugular vein is 
exposed and drawn to one side or divided between the liga- 
tures ; the superficial fascia is next divided upon a director ; 
the posterior belly of the omo-hyoid muscle is next found 
and drawn upward and outward ; the outer border of the 
scalenus anticus is next felt for and followed down to the 
tubercle of the first rib — the artery lies against this, between 
it and the lowest bundle of the brachial plexus. The artery 
is next denuded with the director and the needle is passed 
from below, care being taken not to include the lowest 
bundle of the brachial plexus in the ligature. (Fig. 310.) 



Ligation of the Vertebral Artery. 

Incision for the ligation of the vertebral artery is three 
or three and a half inches in length, parallel with the ante- 
rior edge of the sterno-cleido-mastoid muscle, ending an 
inch above the clavicle. (Fig. 309, B.) The anterior edge of 
the sterno-cleido-mastoid being exposed the middle cervical 
fascia is divided and the carotid artery and jugular vein 
are exposed and drawn inward. The gap between the 
longus colli muscle and the scalenus anticus muscles is next 
felt for about an inch below the carotid tubercle ; the fascia 
covering it is next torn through and the muscles are sepa- 
rated and the vertebral vein comes into view ; this is held 
aside and the vertebral artery is exposed, and the ligature 
is then passed around it. 



LIGATION OF COMMON CAROTID ARTERY 



399 



Ligation of the Inferior Thyroid Artery. 

Incision for the inferior thyroid artery is the same as 
that for the vertebral artery. (Fig. 309, D.) The anterior 
edge of the sterno-cleido-inastoid muscle being exposed it is 
drawn outward, the middle cervical fascia is next divided 
and the carotid artery and internal jugular vein are drawn 
outward with a retractor. The head being flexed slightly, 
the surgeon feels for the carotid tubercle, and then separates 
the cellular tissue with a director and the artery should be 
found below the carotid tubercle. The needle should be 
passed between the artery and vein. 

Ligation of the Common Carotid Artery. 

The point of election for the ligation of the common 
carotid artery is just above the omo-hyoid muscle, about 



Fig. 311. 




Line of incision for common carotid artery at point of election. (Stimsox.) 

three-quarters of an inch below the bifurcation of the vessel, 
which takes place at a point on a line with the upper border 
of the thyroid cartilage. 



400 



LIGATION OF ARTERIES. 



Incision for the common carotid artery, is three inches 
in length along the anterior border of the sterno-cleido- 
mastoid muscle, the centre of which corresponds with the 
crico-thyroid space. (Fig. 311.) 

Divide the skin, platysma and cellular tissue and aponeu- 
rosis, avoiding the superficial veins, and expose the ante- 
rior edge of the sterno-cleido-mastoid ; seek for the inter- 




^ -.Descendens 

N *n,oni> nerve 

••"---"Omo-7i 

N \ muscic 

. j;..Carctid 

\artery 



\- ::: ^>'-<-"'-Int*iuffular 



AnL'? border cf Sterrm 
Mastoid Muscle 



Ligation of common carotid artery. Ligation of facial artery. (Bryant.) 



space between this muscle and the sterno-hyoid and sterno- 
thyroid muscles, draw the latter muscles inward and the 
artery will be exposed with the jugular vein external to it; 
the descendens noni nerve lying upon its sheath, which 
should be displaced outward. The sheath is next picked up 
and opened and the artery is separated from it with a director ; 



EXTERNAL CAROTID ARTERY, 



401 



the artery lies internally, the internal jugular vein externally 
and somewhat more superficial, and the pneumogastric nerve 
lies between the two and is more deeply placed. (Fig. 312.) 




Relation of the left common carotid artery above the omo-hvoid muscle. 
Esmarch.) 

The sympathetic nerve is posterior to the vessel external to 
the sheath. . The needle is passed from without inward, care 
being taken to avoid injury of the vein and nerve. (Fig. 
313.) 

Ligation of the External Carotid Artery. 



Incision for the ligation of the external carotid artery is 
over the inner edge of the sterno-cleido-mastoid muscle from 
the angle of the jaw to a point corresponding to the middle 
of the thyroid cartilage. (Fig. 314. B) The skin, platysma 
and cellular tissue being divided, the external jugular vein 
is drawn aside when encountered : the deep fascia being 



402 



LIGATION OF ARTERIES 



opened, the facial and lingual veins will be exposed, which 
should be drawn to one side; the artery is next exposed 
covered by the hypoglossal nerve and the stylo-hyoid and 
digastric muscles. The vessel should next be isolated from 
the internal carotid artery and internal jugular vein, both of 
which lie along its outer side. The needle should be passed 
from without inward. 

Ligation of the Internal Carotid Artery. 

Incision the same as for the external carotid artery (Fig. 
314, J5); the vessel is external to the external carotid artery, 



Fig. 314. 




Line of incision for — A. Lingual artery. B. External and internal carotid 
artery. C. Occipital artery. D. Temporal artery. E. Facial artery. 

(Stimson.) 

and in passing the needle the point should be directed from 
the internal j ugular vein, that is from without inward. 



LIGATION OF LINGUAL ARTERY 



403 



Ligation of the Superior Thyroid Artery. 

Incision about three inches in length along the anterior 
border of the sterno-cleido-mastoid muscle, starting a little 
lower down than that for the external carotid artery. The 
skin, superficial fascia, platysma, and deep fascia being di- 
vided, the cellular tissue in the sulcus between the upper 
portion of the larynx and the great vessels of the neck is 
broken up with the director and the vessel is exposed. The 
needle should be passed around the vessel from above down- 
ward. 

Ligation of the Lingual Artery. 

Incision a curved one two inches long, its concavity di- 
rected upward from the anterior edge of the sterno-cleido- 
mastoid muscle, half an inch above the great horn of the 

Fig. 315. 




Relations of the lingual artery. (Esmarch.) 



hyoid bone, to a point one inch short of the median line of 
the neck. (Fig. 314, A.) Divide the skin and platysma, 
displacing the superficial veins, and open the deep fascia, 
when the submaxillary gland will be exposed ; this is dis- 
placed upward with the handle of the knife and the tendon 



404 LIGATION OF ARTERIES. 

of the digastric muscle attached to the hyoid bone, and the 
hypoglossal nerve will be exposed ; next divide the fibres of 
the hyoglossus muscle midway between the hypoglossal 
nerve and the hyoid bone, and the lingual artery will be ex- 
posed. (Fig. 315.) 

The needle should be passed around the vessel from above 
downward in order to avoid the nerve. 

Ligation of the Facial Artery. 

The facial artery passes over the inferior maxilla just in 
front of the anterior edge of the masseter muscle and is 
accompanied by the facial vein, which lies nearer to the 
muscle. 

Incision either a horizontal one along the lower border 
of the maxilla or a vertical one an inch in length. (Fig. 
314, E.) The skin, subcutaneous tissue, and fascia being 
divided, the artery is exposed and the needle should be passed 
around the vessel away from the vein. 

Ligation of the Occipital Artery. 

Incision two inches in length, starting from a point half 
an inch below and in front of the apex of the mastoid pro- 
cess carried obliquely backward parallel to the border of 
this process. (Fig. 314, C) Divide the skin and fascia 
and expose the insertion of the sterno-cleido-mastoid muscle, 
which is also divided, and the aponeurosis of the splenius is 
exposed ; this is also opened and the digastric groove is felt 
for, and when the belly of the digastric muscle is exposed 
the artery is brought into view by separating the cellular 
tissue in the anterior angle of the wound with a director. 
(Fig. 316.) 

Ligation of the Temporal Artery. 

Incision a transverse one, one inch in length, starting 
from the tragus of the ear forward over the zygomatic arch 



LIGATION OF AXILLARY ARTERY. 



405 



(Fig. 313, D). or a vertical one of the same length a little 
in front of the tragus of the ear. 

Divide the skin and expose the subcutaneous cellular 
tissue, which in this region is verv dense and fibrous. This 



Fig. 316. 



Fig. 317. 





Ligation of the occipital artery. 
(Skey.) 



Ligation of the temporal artery. 
(Skey.) 



tissue should be broken up with a director and the artery 
should be found in it about a quarter of an inch in front of 
the ear. (Fig. 317.) The temporal vein accompanies the 
artery and lies nearer to the ear, and in some cases the 
auriculotemporal nerve is in close relation to the artery. 
The needle should be passed from behind forward. 

Ligation of the Axillary Artery. 



The axillary artery extends from the middle of the 
clavicle to the insertion of the teres major into the humerus ; 
the axillary vein lies upon the inner side and in front of the 
artery. The axillary artery is tied either in its upper por- 
tion, just below the clavicle, or at its lower portion in the 
axilla. 

Ligation of the Axillary Artery Below the Clavicle. 

Incision four inches in length from the summit of the 
coracoid process inward a short distance below the clavicle 

18* 



406 



LIGATION OF ARTERIES. 



(Fig. 309, E), or an incision three inches in length com- 
mencing at a point one-half an inch from the sterno-clavicu- 
lar articulation and carried obliquely downward toward the 
axilla. 

The skin and subcutaneous tissue having been divided 
the deep fascia is exposed and opened, or the axillary artery 
may be reached by following the intermuscular space be- 
tween the sternal and clavicular fibres of the pectoralis 
major which leads upward toward the clavicle and to the 
pectoralis minor; or the fibres of the pectoralis major being 
exposed are cut through and the costo coracoid fascia is next 
torn through with a director, care being taken to avoid in- 
jury of the cephalic vein at the outer portion of the wound ; 
the pectoralis minor is now seen, and after separating the 
cellular tissue with a director the axillary vein is seen cross- 
ing from the upper edge of the muscle to the clavicle ; the 

Fig. 318. 




A. Incision for axillary artery in axilla. B. Incision for brachial artery. 

(Stimson.) 

vein almost completely covers the artery, which is exposed 
by drawing the vein inward. The needle is passed around 
the artery from within outward. 



Ligation of the Axillary Artery in the Axilla. 

Incision two and a half inches long, started at the upper 
part of the axilla and carried down the arm at the edge of 



LIGATION OF BRACHIAL ARTERY. 



407 



the coraco-brachialis muscle. (Fig. 318, A.) The skin only 
is divided in the first incision and the deep fascia is picked 
up and divided upon a director, and the fibres of the inner 
border of the coraco brachialis muscle are exposed and held 
aside by a retractor, and the operator will see the median 
nerve, the musculo- cutaneous nerve, and the axillary artery. 
To the inner side of the artery are the axillary vein, ulnar 

Fig. 319. 




Relations of right axillary artery in axilla. (Esmarch.) 

and internal cutaneous nerves. The needle should be passed 
around the artery from the vein toward the coraco-brachialis 
muscle. 

Ligation of the Brachial Artery. 



Incision at the middle of the arm three inches long on a 
line corresponding to the inner edge of the biceps muscle. 
(Fig. 318, B.) The skin and cellular tissue being divided', 
care being taken not to injure the basilic vein, which should 
be drawn posteriorly, the deep fascia is next cut through 
and the fibres of the biceps muscle are exposed (Fig. 320) ; 



408 



LIGATION OF ARTERLES. 



this should be drawn forward and the sheath of the vessels 
enclosing the artery, veins, and median nerve is exposed ; 



Fig. 320. 




Relations of right brachial artery at middle of arm. (Esmarch.) 

this is opened, the median nerve is pressed aside and the 
artery is separated from its veins and the needle is passed 
from the side of the nerve around the vessel. 

Fig. 321. 
Tendinous J/wneurof is 
divided 




^^^§§^|^§^?$Ss|^^ : 




Ligation of the brachial artery at bend of elbow. (Bryant.) 



In ligating the brachial artery the occasional high division 
of the vessel must be borne in mind. 



LIGATION OF RADIAL ARTERY. 409 

Ligation of Brachial Artery at Bend of Elbow. 

Incision two inches in length, along the inner border ot 
the tendon of the biceps muscle. Divide the skin, superficial 
fascia, and the bicipital aponeurosis, under which the artery 
will be exposed, resting upon the brachialis anticus muscle. 
(Fig. 321.) The median nerve is to the inner side and some 
distance from the artery. The needle should be passed around 
the vessel, after isolating the veins, from within outward. 



Ligation of the Radial Artery. 

The radial artery extends in a straight line from a point 
half an inch below the centre of the fold of the elbow to 
the inner side of the styloid process of the radius. 

The radial artery may be tied at its upper, middle, or 
lower third, or at the root of the thumb. 

Ligation of the Radial Artery in the Upper Third of the 
Forearm. 

Incision for the radial artery at its upper third is two and 
a half inches in length on a line drawn from the middle of the 
bend of the elbow to the ulnar side of the styloid process 
of the radius ; the incision should begin one and a half 
inches below the bend of the elbow. (Fig. 322, A.) Divide 
the skin and superficial fascia, avoiding the superficial veins. 
When the deep fascia is exposed find the edge of the supi- 
nator longus muscle and divide the aponeurosis along its 
ulnar side and expose the fibres of the pronator radii teres 
muscle. The vessel lies in the interspace between these 
muscles surrounded by adipose tissue, and upon being ex- 
posed the veins should be isolated and the needle passed from 
without inward. The nerve lies so far external to the artery 
that it is not often exposed in the operation. (Fig. 323.) 

Ligation of the Radial Artery in the Middle Third of the 
Forearm. 

IncUion two inches in length, following the same line as 
that for the upper third of the artery. After dividing the 



410 



LIGATION OF ARTERIES 



skin, superficial and deep fascia, the artery is found in the 
interspace between the flexor carpi radialis on the inner side 



Fig. 322. 





Relations of right radial artery 
in the upper third of the forearm. 
(Esmarch.) 



Fig. 324. 



Line of incision for — A. Radial 
artery in upper third. B. Radial 
artery in lower third. C. Ulnar 
artery in upper third. D. Ulnar 
artery in lower third. (Stimson.) 




Relations of right radial artery 
above the wrist. (Esmarch.) 



and the supinator longus on the outer side; the radial nerve 
at this part of the arm is in close relation with the vessel to 
the radial side, and the needle should be passed around the 
artery from without inward. 



LIGATION OF ULNAR ARTERY. 411 



Ligation of the Radial Artery in the Lower Third of the 
Forearm. 

Incision two inches in length following the same line 
(Fig. 822, B), ending one inch above the wrist. The skin, 
superficial fascia, and deep fascia being divided, the artery 
will be found between the tendon of the flexor carpi radialis 
on the inner side and the tendon of the supinator longus on 
the outer side. (Fig. 324.) The veins being separated the 
needle may be passed in either direction. 

Ligation of the Radial Artery at the Root of the Thumb. 

The radial artery may also be tied at the root of the 
thumb. 

Incision one inch in length between the tendons of the 
extensor ossis metacarpi pollicis and extensor primi inter- 
nodii pollicis on the outer side, and the tendon of the ex- 
tensor secundi internodii pollicis on the inner side. The 
skin and superficial fascia being divided and the radial vein 
being displaced, the deep fascia is opened and the artery is 
exposed at the bottom of the wound; the needle may be 
passed in either direction. 



Ligation of the Ulnar Artery. 

The ulnar artery is tied at the junction of the upper and 
middle third of the forearm and at the lower third. 

Ligation of the Ulnar Artery at the Junction of the Upper 
and Middle Thirds of the Forearm. 

Incision three inches in length, starting four inches below 
the internal condyle of the humerus, on a line passing from 
the internal condyle of the humerus to the outer border of 
the pisiform bone. (Fig. 322, C.) Divide the skin and 
superficial fascia, and when the deep fascia has been exposed 
the interspace between the flexor carpi ulnaris and the flexor 
sublimis digitorum appears, enter this interspace and raise 



412 



LIGATION OF ARTERIES. 



the flexor sublimis digitorum and work transversely across the 
arm, and the artery will be found resting upon the deep flexor, 
with the ulnar nerve to the ulnar side. The needle should 
be passed from the nerve around the artery. (Fig. 325.) 



Fig. 325. 




Relations of the right ulnar artery at upper third of forearm. (Esmarch.) 



Fig. 326. 



Ligatioii of the Ulnar Artery in the Lower Third of the 

Forearm. 

Incision two inches in length a little to the radial side of 
the tendon of the flexor carpi ulnaris, which is attached to 

the pisiform bone, ending an 
inch above the wrist. (Fig. 
322, B.) Divide the skin and 
superficial fascia and open the 
deep fascia, and the artery will 
be exposed, with accompanying 
veins, between the tendons of the 
flexor carpi ulnaris and flexor 
sublimis digitorum, the ulnar 
nerve being to the ulnar side of 
the vessel. The needle should 
Relations of right ulnar artery be passed from within outward 
above the wrist. (Esmarch.) to avoid the nerve. (Fig. 326.) 




LIGATION OF COMMON ILIAC ARTERY. 413 

Ligation of the Interosseous Artery. 

Incision similar to that employed in the ligation of the 
ulnar artery in its upper third. 

Ligation of the Abdominal Aorta. 

Incision in the linea alba from a point three inches above 
the umbilicus to a point three inches below it. The super- 
ficial structures being divided the peritoneum is opened 
upon a director, and the intestines are pressed aside and 
the aorta is exposed covered by peritoneum, with the fila- 
ments of the sympathetic nerve resting upon it, and the 
vena cava to the right side. Tear through the peritoneum 
and pass the needle from left to right around the vessel. 
After tving the ligature the ends should be cut short, and 
the external wound should be closed as in the ordinary 
laparotomy wound. 

The vessel may also be exposed by an incision along the 
anterior border of the quadratus lumborum muscle, from the 
last rib to the crest of the ilium. The skin, lumbar muscles, 
and fascia transversalis being divided, the wound is held 
open with blunt hooks, so that the retro-peritoneal space is 
exposed and the aorta brought into view. The vessel being 
separated from the vena cava and nerves, the needle is 
passed around it and the ligature applied. 

Ligation of the Common Iliac Artery. 

The aorta divides into the two common iliac arteries on the 
left side of the fourth lumbar vertebra, and these arteries 
are usually about two inches in length, and bifurcate oppo- 
site the sacro-iliac synchondrosis to form the internal and 
external iliac arteries ; the length of the common iliac artery, 
however, may vary considerably, being three or four inches 
in length in some cases. 

Incision for ligation of the common iliac artery is four to 
six inches in length, beginning one-half inch above the middle 



414 



LIGATION OF ARTERIES 



of Poupart's ligament, and is carried outward curving up- 
ward after passing the anterior superior spine of the ilium. 
(Fig. ,327, A.) 

Divide the skin, superficial fascia and aponeurosis of the 
external oblique muscle, and then divide the fibres of the in- 
ternal oblique and transversalis muscles upon a director, and 
expose the transversalis fascia. This is opened at the lower 



Fig. 327. 




Line of incision for — A, common iliac artery. B, external iliac artery. 
C, femoral artery in Scarpa's triangle. (Stimson.) 

part of the wound, and the finger is introduced and the 
peritoneum is pressed back ; the opening in the transversalis 
fascia is next enlarged, and the peritoneum is carefully 
drawn inward and upward with the fingers toward the inner 
edge of the wound. The operator next feels for the external 
iliac artery, and passes the finger along this until the common 
iliac artery is reached. The loose cellular tissue in which it 
is imbedded is next separated, and the needle is passed from 
within outward, to avoid the common iliac vein (Fig. 328), 



LIGATION OF INTERNAL ILIAC ARTERY. 415 

which on the left side lies on the inner side of the artery, 
and on the right side it lies behind the artery. The ureter 
generally remains attached to the peritoneum ; if not, it is 
seen crossing the bifurcation of the common iliac with the 

Fig. 328. 




Ligation of the common iliac artery. (Liston.) 

genito-crural nerve, and care should be taken to avoid injury 
of these structures if present. 

The common iliac artery may also be exposed and tied by 
an incision made over the artery through the peritoneal 
cavity ; the vessel being tied, the ends of the ligature are 
cut short, and the external wound is closed in the same 
manner as that resulting from the exposure of the abdominal 
aorta by incision through the peritoneum. 

Ligation of the Internal Iliac Artery. 



Incision in the same line as for the common iliac artery, 
but it need not be quite so long. (Fig. 327, A.) The peri- 



416 



LIGATION OF ARTERIES. 



toneum being exposed, it is pushed upward and inward, and 
the internal iliac artery is exposed. The vessel is carefully 
isolated from the vein, which lies behind and on the inner 
side, and the needle is passed from within outward. 



Ligation of the External Iliac Artery. 

Incision three or four inches in length, half an inch 
above the middle of Poupart's ligament, made at first par- 
allel to it and then curved upward. (Fig. 327, B.) The 
tissues of the abdominal wall being divided and the peri- 




Relations of the right external iliac artery. (Esmarch.) 



toneum exposed, it is pushed upward and inward in the 
same manner as for exposure of the common iliac artery. 
The artery lies at the inner border of the psoas muscle, the 
vein on its inner side, and the anterior crural nerve covered 
by the iliac fascia on the outer side ; the genito-crural nerve 
passes obliquely across the artery. (Fig. 329.) The needle 
should be passed from within outward. 



SCIATIC AND INTERNAL PUDIC ARTERIES. 417 



Ligation of the Gluteal Artery. 



Incision three or four inches in length, from the posterior 
superior spinous process of the ilium to a point midway 
between the tuber ischii and the great trochanter. (Fig. 
330, A.) After division of the skin and fascia, the fibres 



Fig. 330. 




Line for — A, gluteal artery. B, sciatic and internal pudic artery. (Stimson.) 

of the gluteus maximus muscle are separated and held apart, 
and the deep fascia is divided, and the artery is sought for 
above the pyriformis muscle at the upper border of the great 
sacro-sciatic notch. It is accompanied by large veins, injury 
to which should be avoided in exposing the artery and pass- 
ing the needle. 

Ligation of the Sciatic and Internal Pudic 
Arteries. 

Incision three or four inches in length, a little lower than 
that employed for exposure of the gluteal artery. (Fig. 330, 



418 



LIGATION OF ARTERIES. 



B.) Divide the skin, superficial fascia and fibres of the 
gluteus maximus muscle and deep fascia, and search for the 
vessels as they leave the great sciatic notch at the lower edge 
of the pyriformis muscle. The internal pudic artery enters 
the pelvis through the lesser sciatic notch, lying on the inner 
side of the sciatic artery during its passage over the spine of 
the ischium. The vessels are isolated and the needle is passed 
so as to avoid injury of the veins. 

Ligation of the Femoral Artery. 

The femoral artery may be ligated just below Poupart's 
ligament, at the apex of Scarpa's triangle, at the middle of 
the thigh, or in Hunter's canal. 

Ligation of the Femoral Artery below Poupart's 
Ligament. 

Incision beginning midway between the anterior supe- 
rior spinous process of the ilium and the symphysis pubis, 

Fig. 331. 




Relations of the right femoral artery below Poupart's ligament. (Esmaech.) 



LIGATION OF FEMORAL ARTERY. 



419 



one-fourth of an inch above Poupart's ligament, and ex- 
tending ten inches downward. Divide the skin and super- 
ficial fascia and the deep fascia and expose the sheath of 
the vessels ; open this one-half an inch below Poupart's 
ligament and isolate the femoral artery from the femoral 
vein which lies to the inner side ; the anterior crural nerve 
lies to the outer side. Pass the needle from within outward. 






Ligation of the Femoral Artery at the Apex of Scarpa s 
Triangle. 

Incision three inches long, the centre of which should be 
a little above the point where the sartorius muscle crosses 
a line drawn from the middle of Poupart's ligament to the 
inner condyle of the femur. (Fig. 332.) Divide the skin, 



Fig. 332. 

— - 




Lines of incision for the femoral artery. (Stimson.) 



superficial fascia and deep fascia, avoiding the internal 
saphenous vein, and expose the edge of the sartorius muscle, 
which may be recognized by the direction of its fibres. 
This muscle is drawn outward and the sheath of the vessels 
is exposed and opened ; the vein lies on the inner side and 
somewhat behind the artery and the long saphenous nerve 
is on the outer side. (Fig. 333.) Pass the needle from 
within outward. 



420 



LIGATION" OF AKTERIES, 



Ligation of the Femoral Artery in the Middle of the 
Thigh. 

Incision in the line above mentioned, its centre being a 
little above the middle of the thigh. Divide the skin, super- 



Fig. 333. 



Fig. 334. 





Eelations of right femoral 
artery at the apex of Scarpa's 
triangle. (Esmarch.) 



Eelations of the right femoral 
artery in the middle of the thigh. 
(Esmarch.) 



ficial and deep fascia and expose the sartorius muscle which 
is drawn outward after the leg has been flexed; the sheath 
of the vessels is exposed and opened ; the long saphenous 
nerve lies upon the artery and the femoral vein lies behind 
the artery; the saphenous vein lies more superficially and 
internal to the vessel. Pass the needle from within out- 
ward. (Fig. 334.) 

Ligation of the Femoral Artery in Hunter s Canal. 

Incision three inches in length along the tendon of the 
adductor magnus, the centre of which is at the junction of 
the lower and middle thirds of the thigh. (Fig. 332.) 
Divide the skin, superficial fascia and deep fascia, care being 



LIGATION" OF POPLITEAL ARTERY 



421 



taken not to injure the internal saphenous vein, which should 
be displaced and expose the sartorius muscle, which should 
be displaced downward and expose the aponeurosis which 
forms the anterior wall of the vascular canal ; this should 
be opened upon a director, and the artery is uncovered and 
should be separated from the vein, which lies upon the outer 
side. The needle is passed from without inward. 

Ligation of the Popliteal Artery. 

Indsion three or four inches in length, along the exter- 
nal border of the semi-membranosus muscle. Divide the 



Fig. 33! 




Relations of the right popliteal artery. (Esmabch. 

skin and superficial fascia, taking care not to injure the 
saphenous vein, and open the deep fascia. The edges of the 

19 



422 



LIGATION OF ARTERIES 



wound being held apart the adipose tissue is broken up 
with a director, and the internal popliteal nerve will be first 



Fig. 336. 




• ./ 



Ligation of popliteal artery. (Smith.) 



exposed, and next the vein — both external to the artery. 
(Fig. 335.) The artery is isolated and the needle is passed 
from without inward. (Fig. 336.) 

Ligation of the Anterior Tibial Artery. 

The anterior tibial artery may be tied in the upper, 
middle, and lower thirds of the leg ; the general direction 
of the artery corresponds with a line drawn from the middle 
of the space between the head of the fibula and the tubercle 
of the tibia to the middle of the anterior intermalleolar space. 



Ligation of the Anterior Tibial Artery in the Upper Third 
of the Leg. 

Incision two and a half to three inches in length, one 
and one-fourth inches external to the spine of the tibia. 
Divide the skin and superficial fascia, and when the deep 
fascia is exposed open it on a line corresponding to the 
intermuscular space between the tibialis anticus and the 



LIGATION OF ANTERIOR TIBIAL ARTERY. 423 



extensor longus digitorum muscles. 
Separate the muscles and work 
down in this interspace, and the 
artery will be found with a vein on 
either side of it, and the anterior 
tibial nerve externally. (Fig. 337.) 
The needle should be passed from 
without inward, 
veins. 



Fig 337. 



after isolating the 



Ligation of the Anterior Tibial 
Artery at its Middle Third. 

Incision three inches in length 
in the same line as that for the 
upper portion of the vessel. After 
dividing the skin, superficial and 
deep fascia, the interspace between 
the tibialis anticus and the ex- 
tensor longus digitorum muscles is 
opened and a third muscle comes in 
view, the extensor proprius pollicis 
The artery lies between the ex- 
tensor proprius pollicis and the tibialis anticus muscles, and 
the anterior tibial nerve is to the outer side. The veins 
should be isolated and the needle should be passed from with- 
out inward. 




Ligation of the anterior 
tibial artery at its upper 
third. (Stimson.) 



Ligation of the Anterior Tibial Artery in its Lower Third. 

Incision two inches in length, beginning three inches 
above the ankle-joint on the line of the artery. Divide the 
skin, superficial and deep fascia, and seek for the tendon of 
the extensor proprius pollicis muscle, the second tendon 
from the tibia. The artery is found in the interspace be- 
tween this tendon and the tendon of the extensor longus 
digitorum muscle, the nerve being to the outer side. The 
veins are isolated from the artery, and the needle is passed 
from without inward. 



424 



LIGATION OF ARTERIES. 



Ligation of the Dorsalis Pedis Artery. 

Incision one inch in length on a line drawn from the 
middle of the anterior inter-malleolar space to a point midway 
between the extremities of the first two metatarsal bones or 
along the outer border of the tendon of the extensor proprius 
pollicis. Divide the skin, superficial and deep fascia, and 

Fig. 338. 



muscle 




Extensor 
Tj/rvis cliff Horn mi-- — r If^ ,| Te/ir7on of 
--WTs/esiso/ 
:d//ro/irius 
I /lollicis 

i 



Ligation of the dorsalis pedis artery. (Bryant.) 

the artery will be found lying next to the inner tendon of 
the short extensor muscle of the toes. (Fig. 338.) The 
nerve is to the outer side. After separating the veins the 
needle is passed from without inward. 

Ligation of the Posterior Tibial Artery. 



The course of the posterior tibial artery is indicated by a 
line drawn from the middle of the popliteal space to a point 



LIGATION OF POSTERIOR TIBIAL ARTERY. 425 



midway between the tendo 
Achillis and the internal mal- 
leolus of the tibia. 

The posterior tibial artery 
may be ligated in its upper, 
middle, and lower thirds. 

Ligation of the Posterior Tibial 
Artery at its Upper Third. 

Incision three inches and a 
half in length, one-half inch 
from the inner edge of the tibia, 
beginning two inches from the 
upper edge of the tibia. (Fig. 
339.) Divide the skin and 
superficial fascia, avoiding 
large superficial veins; next 
open the deep fascia and detach 
the origin of the soleus muscle 
from the tibia, and on raising 
it, its under surface will pre- 
sent a white shining sheath of 
tendinous material, beneath 
which will be seen a layer of 
fascia covering the tibialis pos- 
ticus muscle. If search is 
made toward the middle of 
the leg, the artery will be 
found covered by the inter- 
muscular fascia, the nerve 

being to the outer side. The needle is passed from without 
inward after the veins have been separated from the artery 
(Fig. 340). 




Lines of incision for the posterior 
tibial artery. (Stimsox.) 



Ligation of the Posterior Tibial Artery at its Middle Third. 

Incision two and a half inches in length, parallel with 
the inner edge of the tibia and half an inch from its border. 



426 



LIGATION OF ARTERIES. 



Divide the skin, superficial and deep fascia, and the inner 
edge of the soleus will be exposed ; press this outward and 



Fig. 340. 




Relations of the right posterior tibial artery in its upper third. (Esmaech.) 

the artery with its veins will be exposed, also the posterior 
tibial nerve to the outer side. Pass the needle from without 
inward after separating the veins. 



Ligation of the Posterior Tibial Artery Behind the Inner 
Malleolus. 

Incision a curved one two inches in length, midway be- 
tween the tendo Achillis and the internal malleolus. (Fig. 
339.) Divide the skin and superficial fascia and lift the 
deep fascia upon a director and open it freely and the artery 
will be exposed with the tendons of the tibialis posticus and 
flexor longus digitorum muscles on the inuer side and the 
posterior tibial nerve and the tendon of the flexor longus 



LIGATION OF POSTERIOR TIBIAL ARTERY. 427 

Fio 341. 




Ligation of the posterior tibial artery behind inner malleolus. (Bryant.) 

pollicis muscle on the outer side. (Fig. 341.) After sepa- 
rating the veins from the artery the needle should be passed 
from without inward. 



PAET VI 



AMPUTATIONS 



The term amputation is now generally applied to the re- 
moval of a limb, and this may be removed through the 
bones, when the operation is spoken of as an amputation in 
the continuity of the limb ; or it may be removed through 
its joints, and is then known as an amputation in the con- 
tiguity or a disarticulation. 

Methods of Amputating. 

Amputations may be performed by the circular, flap, 
oval, and elliptical methods; the modified circular operation, 
and Teales method by rectangular flaps, are also employed. 




Amputation by circular method. (Druitt.) 



METHODS OF AMPUTATING. 



429 



Fig. 343. 



Circular Method. 

In performing an amputation by this method the incision 
of the skin is made at a distance below the point where the 
bone is to be divided. An assistant grasps the limb and 
draws the skin evenly and firmly toward the root of the 
part and the surgeon passes the heel of the knife well into 
the tissues and makes a circular 
sweep around the limb and com- 
pletes the division of the skin 
and cellular tissue with one mo- 
tion of the knife. (Fig. 342.) 

In some cases a cutaneous 
sleeve consisting of the skin and 
cellular tissue is dissected up and 
turned back, and sometimes it 
may be necessary to make a slit 
on one side of the flap to allow 
it to be turned up. 

The second incision in an am- 
putation by the circular method 
consists, after retraction of the 
skin, in making a circular cut 
through all of the tissues down to the bone. (Fig. 343.) 

The third step in an amputation by the circular method 
consists, after retracting the skin and muscles and holding 
them back by a retractor, in the division of the bone with 
a saw. 

Flap Method, 

This method of amputating is susceptible of many varia- 
tions. There may be one or two flaps of equal or unequal 
length ; the flaps may be cut antero-posteriorly, laterally, or 
obliquely. (Fig. 344.) They may be made by transfixing 
the limb and cutting outward, or they may be cut from 
without inward, or they may be made to include the whole 
thickness of the tissues down to the bone, or merely the skin 
and superficial fascia, the deeper structures being divided 
by a circular incision. The flaps may have a curved outline 

19* 




Division of muscles in circular 
amputation. (Smith.) 



430 



AMPUTATIONS 



or may be rectangular in shape. In amputating by the 
anteroposterior flap operation the surgeon grasps the limb 



Fig. 344. 




Double-flap amputation; antero-posterior and lateral flaps. (S. Smith.) 

and enters the point of a long knife into the tissues at the 
side nearest himself, and pushing it across and around the 



Fig. 345. 




Amputation by antero-posterior flaps. (Bryant.) 

bone or bones brings its point out through the skin at a 
point diametrically opposite its point of entrance. He then 
shapes the flap by cutting downward with a rapid sawing 



METHODS OF AMPUTATING. 



431 



motion and then cuts obliquely forward until all the tissues 
are divided. The flap being turned up, he reenters his 
knife at the same point and passes it on the other side of 
the bone or bones and cuts the second flap in the same 
manner. (Fig. 345.) A retractor is next applied and the 
bone is divided with a saw. 



The Oval Method. 

The oval amputation is really a circular one in w T hich the 
cuff of skin has been slit at one side and the angles rounded 
off. This is the form of amputation frequently performed at 
the metacarpophalangeal and metatarso- phalangeal joints, 
and is one of the methods of amputation at the shoulder- 
joint. 

Elliptical Method. 

This is a form of the oval method of amputation which 
is employed in amputations at the knee- and elbow-joints, 
the incision forming an ellipse coming below the joint on 
the front or outside of the limb, the resulting flap being 
folded upon itself. 

Fig. 346. 




Modified circular amputation. (Skey.) 



432 AMPUTATIONS. 

Modified Circular Method. 

In this method of amputation two oval skin flaps, antero- 
posterior or lateral, are turned up, and the muscles are next 
divided by a circular sweep of the knife down to the bone 

(Fig. 346). 

Teales Method by Rectangular Flaps. 

In this method of amputation, two flaps are made of un- 
equal length ; the incisions are so planned that the shorter 
flap contains the main vessel or vessels. The flaps are cut 
of equal width and the length of the long flap should be 
one-half of the circumference of the limb at the point where 
the bone is to be divided ; the length of the short flap should 
be one-eighth of the circumference of the limb. The flaps 
are cut from without inward, and embrace all of the tissues 
of the limb down to the bone. After the flaps have been 
dissected up, the bone is divided with a saw, and the long 
flap is folded over and sutured to the short flap (Fig. 347). 

Fig. 347. 




Teale's method of amputation. (Bryant.) 

The disadvantage of this method of amputation is that in 
muscular limbs it requires the bone to be divided at a higher 
point than would otherwise be necessary. 



INSTRUMENTS FOR AMPUTATIONS. 



433 



Periosteal Flaps. 

In any of the methods of amputation previously described 
the periosteum may be dissected up in two flaps attached to 
the muscles, or pushed up as a sleeve by means of a direc- 
tor or periosteotome before the bone is sawed. This pro- 
cedure is most easily accomplished in young subjects. When 
these flaps are made and they are brought together, the 
periosteum covers the cut surface of the bone, to which it 
soon forms adhesions. 

Instruments Required for Amputations. 

The instruments required for amputations are knives of 
various shapes and sizes, saws, dissecting forceps, bone for- 
ceps, artery forceps, tenacula, haemostatic forceps, scissors, 
periosteotome, tourniquets, Esmarch's bandage and strap, 
retractors, ligatures, sutures, and suture needles. 

Amputating Knives. 

The knives required for amputations vary according to 
the method of amputation and the part to be amputated. 

Fig. 348. 



Scalpel. 
Fig. 349. 



Straight bistoury. 

In certain amputations a scalpel (Fig. 348) or straight bis- 
toury may be used (Fig. 349), while in other cases the em- 
ployment of amputating knives of various sizes will be 
found more satisfactory. For amputations of the thigh a 
knife with a blade of eight or nine inches is generally em- 



-±34 AMPUTATIONS. 

ployed, and for smaller limbs a knife with a blade of six or 
seven inches in length ; double-edged catlins are employed in 

Fig. 350. ■ 



LCYLENTZ &SONS 
Amputating knife and catlin. 

amputations of the leg and forearm to divide the inter- 
osseous tissues before applying the saw. The amputating 
knives now employed are constructed with solid metal 
handles so that they can be rendered thoroughly aseptic by 
immersion in boiling water before being used. 

Amputating Saivs. 

Several kinds of amputating saws are in general use ; one 
with a blade ten inches long by two and a half inches wide, 

Fig 351. 




Amputating saw. 
Fig. 352. 




Small amputating saw, 



with a heavy back to give it additional firmness, is a very 
good variety of saw (Fig. 351). For amputations about the 
foot or hand a narrow saw with a movable back will be 



INSTRUMENTS FOR AMPUTATIONS. 



435 



found very convenient. (Fig. 352.) A bow saw with a 
metallic handle and a reversible blade is a very useful 
variety of saw, as it can be used either in amputations or in 



Fig. 353. 



C\ 




vs>t.--;jt<=^-~vji 



Amputating saw with reversible blade. 

excisions, and, being constructed entirely of metal, it can be 
easily rendered aseptic. (Fig. 353.) 

Bone Forceps, or Cutting Pliers. 

These instruments are used in smoothing off any rough 
edges of bone left after the use of the saw, or for the division 
of the small bones in amputations of the fingers and toes. 

Fig. 354. 




Bone forceps, or cutting pliers. 

The forceps should be from ten to twelve inches in length, 
with blades from one to one and a half inches in length. 
(Fig. 354.) 

Per {osteotome. 

The periosteotome, or raspatory, is employed for dissecting 
up a flap of periosteum, which, after sawing the bone, is 
drawn down over the sawed end of the bone. (Fig. 355.) 



436 



AMPUTATIONS. 

Fig. 355. 




Periosteotome. 

Artery Forceps and Tenacula. 

These instiuments are used for taking up the vessels, and 
one of the best forms of artery forceps is that known as the 
double-spring artery forceps. (Fig. 188, p. 252.) Tenacula 

Fig. 356. 




Eetractor applied. (Esmarch.) 

are also employed for the same purpose. Hcemostatic for- 
ceps will also be found most useful in cases of amputation, 
for the rapid control of hemorrhage from small vessels after 
the tourniquet has been removed, the vessels being secured 
by ligatures before the haemostatic forceps are removed. 



INSTRUMENTS FOR AMPUTATIONS. 



437 



Retractors. 

These consist of pieces of muslin six or eight inches in 
width, one end of which is split into two or three tails ; the 
former variety of retractor is employed where one bone is 
divided, as in amputations of the arm and thigh, and the 
latter in cases where two bones are divided, as in amputa- 
tions of the forearm and leg. (Fig. 356.) 

Ligatures. 

The best material to employ for the ligature of vessels is 
juniper or chromicized catgut, the preparation of which has 
been described. 

Sutures. 

The materials employed for sutures in cases of amputation 
may be silkworm -gut, catgut, silk, or silver wire ; deep or 
buried sutures of catgut in bringing together the edges of the 



Fig. 357. 



Fig. 35S. 




Deep or buried sutures of muscles. 

| EsMARCH.) 



Sutures of skin. 
(Esmarch.) 



periosteal flaps, muscles, and fascia, are often employed with 
advantage in amputations (Fig. 357), the skin flaps being 
brought together with interrupted or continuous sutures of 
silk, catgut, silkworm-gut, or silver wire. (Fig. 358.) 



438 AMPUTATIONS. 



Tourniquets. 

For the control of hemorrhage during the amputation the 
Esmarch apparatus (Fig. 186), or Petit's tourniquet (Fig. 
179) is employed ; or the employment of both at the same 
time will often be found most satisfactory. The Esmarch 
bandage and tube being applied, after the removal of the 
bandage the tourniquet of Petit is loosely applied at a higher 
point, and after the main vessels have been secured the 
elastic strap is removed and the tourniquet is screwed down 
and controls the bleeding until the smaller vessels have been 
secured by ligatures. 

Details of an Amputation. 

The following are the steps of an amputation of the lower 
part of the thigh : 

The skin is first thoroughly cleansed by rubbing it with 
turpentine and soap and water and is then washed with an 
antiseptic solution either of carbolic acid 1 : 40 or bichloride 
of mercury 1 : 2000. Provision is next made to prevent 
the loss of blood during the operation by the application of 
Esmarch's bandage and tube; the bandage being removed a 
tourniquet is placed over the femoral artery in Scarpa's 
triangle and loosely secured. The limb is again washed with 
bichloride solution. The instruments having been previously 
placed in an antiseptic solution, a rubber cloth covered 
with towels wrung out in a bichloride solution is placed 
under the limb. The variety of amputation having been 
decided upon, the flaps are cut and the muscles are divided 
down to the bone ; the periosteum being dissected up, a two- 
tailed retractor is applied and the tissues are held back by 
an assistant while the surgeon divides the bone with the saw. 
When the bone has been divided the retractor is removed 
and the surface of the wound is irrigated with a 1 : 2000 
bichloride solution. The femoral artery and vein are next 
found and secured with ligatures, and any branches which 
can be found are also secured. The elastic str .p is removed 
after screwing down the tourniquet, and by letting up the 



DETAILS OF AMPUTATION. 



439 



pressure on this, smaller vessels which bleed are picked up 
with artery forceps or hemostatic forceps and secured. 
After all bleeding has been controlled the tourniquet is re- 
moved and the wound is again thoroughly irrigated with a 
1 : 2000 bichloride solution. If there is much oozing from 
smaller vessels this solution should be as hot as the hands of 
the operator can comfortably stand, which will act promptly 
in controlling this variety of bleeding. The periosteal flaps, 
if they have been made, are brought together by two or three 
catgut sutures, and a drainage-tube is next introduced or two 
short tubes are introduced at either extremity of the wound 

Fig. 359. 




Stump showing application of sutures and drainage-tubes. (Smith.) 



and secured by sutures or safety-pins ; the muscles should 
next be brought together by a few deep or buried sutures of 
catgut, and the skin flaps should then be brought into appo- 
sition by a number of interrupted sutures. The inner sur- 
face of the stump is next irrigated by a stream of bichloride 
solution introduced through the drainage-tube, and the sur- 
face of the stump is washed with the same solution ; a 
piece of protective is next placed over the line of the wound 
and over this is placed a moist carbolized, bichloride, or 



440 AMPUTATIONS. 

iodoform gauze dressing, and over this a number of layers of 
dry gauze ; this is next covered by rubber tissue and a num- 
ber of layers of bichloride cotton, or if the dry method of 
dressing is preferred the rubber tissue is omitted and a 
number of layers of bichloride cotton are laid over the 
gauze dressing, and the whole dressing is held in place by a 
recurrent bandage of the stump. 

Re-dressing of Amputations. 

The first dressing of an amputation, if strict antiseptic 
precautions have been observed at the time of operation, 
need not, as a rule, be made for a week or ten days, except 
in cases where the oozing is so profuse as to soak the dress- 
ings, or where consecutive hemorrhage has occurred, or the 
patient's condition shows that the wound is not running an 
aseptic course. The re-dressing of a stump can be accom- 
plished without pain to the patient if the surgeon and his 
assistants are careful in their manipulations. 

The dressings to be applied, the solutions for irrigation, 
and the instruments required should be prepared and at 
hand before the stump is exposed. The surgeon and his 
assistants should wash their hands carefully, and then dip 
them in a 1 : 2000 bichloride solution. The bandage retain- 
ing the dressings to the stump should be divided with ban- 
dage scissors without lifting the stump from the pillow upon 
which it rests. After the bandage has been divided and 
turned aside, the gauze dressing is next unfolded and turned 
down ; an assistant now slips his hands under the stump and 
gently raises it from the dressings, and at the same time a 
rubber cloth covered with towels which have been wrung out 
in a 1 : 2000 bichloride solution is slipped under the stump 
and the soiled dressings are removed. The protective cover- 
ing the incision is next removed and the surface of the 
stump is irrigated with a 1 : 2000 bichloride solution ; the 
drainage-tubes are next examined and the cavity of the 
stump is irrigated with the bichloride solution through the 
tubes by means of a syringe or an irrigating apparatus. 



AMPUTATIONS OF THE FINGERS. 441 

If the wound is aseptic and there seems to be no further 
indication for the use of the drainage-tubes they may be re- 
moved and the track of the tube should be washed out with 
the antiseptic solution by the syringe or irrigator. The sutures 
are next examined and if the wound is firmly healed alternate 
sutures may be removed ; if catgut or silkworm-gut sutures 
have been used they need not be disturbed at this dressing, 
and their removal may be postponed until a subsequent 
dressing. 

The wound should next be covered w T ith a piece of pro- 
tective, and a gauze dressing should be applied consisting of 
a number of layers of bichloride cotton, and the dressings 
should be held in place by a recurrent bandage of the 
stump. In holding the stump the assistant should hold it 
firmly to prevent muscular spasm, and after the dressings 
have been secured it should be placed upon a clean pillow 
prepared for its reception. The same procedures are 
adopted at subsequent dressings, and if the wound has run 
an aseptic course, two or three dressings, at most, will be 
required. 

Special Amputations. 

Amputations of the Hand. 

Amputations of the Fingers. 

The fingers may be amputated in the continuity of the 
phalanges or in their contiguity, and, as a rule, as it is im- 
portant to save as much as possible of the finger, the former 
method is generally to be employed instead of disarticula- 
tion at a higher point. The incisions should be so planned 
that the cicatrix does not occupy the plantar surface ; the 
larger flap should, therefore, be taken from the palmar 
aspect of the finger. In amputating the phalanges of the 
fingers in their continuity the circular method (Fig. 363, B) 
or a short dorsal flap and a long palmar flap may be em- 
ployed. In disarticulating a phalanx it is best to enter 
the joint with a narrow knife from the dorsal side, and after 



442 



AMPUTATIONS. 



having carried it through the joint, to cut a long palmar 
flap, keeping close to the bone. (Fig. 360.) In locating 




Amputation of finger: long palmar flap. (Ertchsen.) 

the position of the phalangeal joints it is well to remember 
that the prominence of the knuckle, when the finger is 
flexed is formed entirely of the head of the proximal, and 

Fig. 361. 





Phalanges flexed. 



Guides to articulations of the finger. 
(Smith.) 



not of the base of the distal phalanx (Fig. 361), and also 
that the folds on the palmar surface of the finger do not 
correspond exactly to the joints. (Fig. 362.) 



AMPUTATIONS OF THE FINGERS. 



443 



Amputation of the Finger' through Metacarpo-phalangeal 
Articulation. 

In this variety of amputation an incision is made from 
a point of the dorsal surface of the metacarpal bone a 
quarter of an inch above the articulation, which is carried 
through the interdigital web and back upon the palmar sur- 



Fig. 363. 




A. Disarticulation of phalanx, palmar flap. B. Amputation in contin- 
uity, circular. C. Metacarpo-phalangeal disarticulation. D. Amputation 
of metacarpal bone in continuity. E. Disarticulation of little finger. F. 
Disarticulation of fifth metacarpal bone. G. Amputation at the wrist, 
circular. H. Amputation at the wrist. (Stimson.) 

face to a point a quarter of an inch above the flexor fold 
(Fig. 363, C). A similar incision beginning and ending at 
the same points is made upon the opposite side of the finger. 
The flaps are dissected back, and the lateral ligaments, ten- 
dons, and remainder of the capsule are divided. The 



444 



AMPUTATIONS 



finger may also be amputated at the metacarpophalangeal 
joint by making an incision on one side and dissecting the 
flap back to the joint, then dividing the lateral ligament, 
opening the joint and carrying the knife across this, divid- 
ing the tendons and lateral ligament on the other side and 
cutting a flap from within outward. 

Removal of the head of the metacarpal bone if desired 
may be accomplished by the use of cutting pliers (Fig. 364), 

Fig. 364. 




Eemoval of head of metacarpal bone. (Skky.) 

but, as a rule, this procedure is not to be recommended, for, 
although the deformity is diminished, the strength of the 
hand is also diminished. 

In amputating the little and index fingers a full lateral 
flap may be cut on the free side and an incision is next car- 
ried across the palmar surface to the angle of the web and 
thence back to the joint, which is opened and the disarticu- 
lation is effected. (Fig. 363, E.) 

In amputations of the finger at the phalangeal joints or 
at the metacarpophalangeal joints two vessels usually re- 



AMPUTATIONS OF THE HAND. 



445 



quire ligaturing, and after these are secured a catgut drain 
or a small drainage-tube is introduced and the flaps are 
brought together by a few interrupted sutures. 

Amputations of the Metacarpal Bones. 

In amputating the metacarpal bones it is advisable to 
leave the carpal ends of the bones to avoid opening the 
wrist-joint, except in the case of the first and fifth meta- 
carpal bones, which do not communicate with the others 
and with the synovial sacs. 

The incisions for the removal of the metacarpal bones 
are the same as for the removal of a finger at the meta- 
carpo-phalangeal joint, the incision being prolonged back- 
ward as far as necessary over the dorsal surface of the bone. 
(Fig. 363, D.) After the metacarpal bone has been bared 
for a sufficient distance, it is cut through with bone-pliers 
or disarticulated, and the distal end is raised from its bed 
and carefully separated from the soft parts, care being taken 
to avoid injury of the structures of the 
palm of the hand. 

In amputating the fifth metacarpal bone 
the incision should be made along the 
inner border of the hand and carried down 
to the bone between the skin and the ab- 
ductor minimi digitii muscle. (Fig. 365.) 
The lower end of the incision passes over 
the knuckle to the web of the finger and 
backward under the palmar surface to join 
the first incision. 

Amputation of the entire thumb with 
its metacarpal bone is effected by making 
an oval flap from the palmar surface ; in 
case of the left thumb the joint may be 
opened by an oblique incision on the dorsal 
surface of the hand, beginning a little in 
front of the joint and being carried down 
to the web between the thumb and fore- 
finger ; the palmar flap is then made by 

20 




Incision for re- 
moval of the fifth 
metacarpal bone. 
('Smith. ) 



446 AMPUTATIONS. 

thrusting the knife upward to its point of entrance and cut- 
ting downward and outward. In amputating the right 
thumb with its metacarpal bone it is better to make the 
palmar flap first by transfixion, the dorsal flap being made 
subsequently. 

Amputation of the hand at the carpo- metacarpal joint 
is occasionally performed, or between the rows of carpal 
bones, but is not as a rule to be recommended, as the carpal 
bones are apt subsequently to become diseased and require 
removal, so that it is better to amputate at the radio-carpal 
joint. 

Amputations at the Wrist. 

Circular Method. 

The skin of the forearm near the wrist being retracted 
by an assistant, a circular incision of the skin and cellular 

Fig. 366. 



Amputation at the wrist. (Erichsen.) 

tissue is made half an inch below the point of the styloid 
process of the radius. (Fig. 363, G-.) The skin and cellu- 
lar tissue are next dissected back as far as the joint, which 
is opened and the disarticulation is completed. 



AMPUTATIONS OF THE FOREARM. 447 

Antero-posterior Flap Method. 

This method is also employed in amputations at the wrist- 
joint ; an incision carried downward is made on the back of 
the hand from one styloid process to the other; the hand 
being flexed the tendons are divided and the joint opened, 
and the palmar flap, which should extend as far as the base 
of the metacarpal bones, is cut from within outward. (Fig. 
366.) Amputation at the wrist is sometimes done by cutting 
a single flap from the palm, the joint being opened by a 
transverse incision on the back of the hand from one styloid 
process to the other. 

Lateral Flap Method. 

This method (Fig. 363, H) is also sometimes employed 
in amputation at the wrist, and may be employed with ad- 
vantage in cases of laceration of the hand, in which the 
injury to the tissues prevents the formation of the flaps used 
in the other methods of amputation. 

Amputations of the Forearm. 

The forearm may be amputated by the circular or flap 
methods, or by making rectangular flaps (Teale's method). 

Circular Method. 

At the lower portion of the forearm the circular method 
of amputation is to be preferred. A circular incision of the 
skin and cellular tissue is made and a cuff is dissected up, 
the muscles and interosseous membrane being cut through ; 
a three-tailed retractor is next applied and the bones are 
divided with a saw. 

Mixed Method. 

Amputation of the forearm by the mixed method, which 
consists in first dissecting up two antero-posterior oval flaps of 
skin and cellular tissue and then dividing the muscles by a 
circular incision, is also a satisfactory operation. (Fig. 367.) 



448 AMPUTATIONS. 

In amputations at the upper portion of the forearm, 
antero-posterior, or lateral flaps, cut from without inward 
or by transfixion, or rectangular flaps may be made with 
advantage. 

Fig. 367. 




Amputation of the forearm by mixed method. (Bryant.) 

The principal vessels requiring the application of liga- 
tures in amputations of the forearm are the radial, ulnar, 
and interosseous arteries. 



Amputations at the Elbow. 

The methods of amputation employed at the elbow are 
the anterior flap, lateral flap, and circular. 

Anterior Flap Method. 

A flap three inches in length with its base parallel to and 
half an inch below the condyles of the humerus, is cut either 
by transfixion or from without inward. The joint is next 
opened and the lateral ligaments divided and the olecranon 
is exposed and the attachment of the triceps is separated 
and a posterior flap is cut from without inward, or from 
within outward a little below the line of the condyles. 
(Fig. 368,4.) 

Lateral Flap Method. 

In amputation at the elbow-joint lateral flaps may be em- 
ployed, cut either from without inward or by transfixion. 
(Fig. 368, B) An external flap three inches in length is 
made on the outer side of the arm, starting from a point a 
finger's breadth below the bend of the elbow, by transfixion 



AMPUTATIONS AT THE ELBOW 



449 



or by cutting from without inward; a shorter internal flap 
is next cut in the same manner, and the joint is opened and 
the disarticulation effected. (Fig. 369.) 



Fig. 368. 



Fio. 3fi9. 




Amputation at the elbow- 
joint. A. Anterior flap 
method. B. External flap 
method. C. Circular method. 
(Stimson.) 




Lateral flap method of amputation at the 
elbow-joint. (Smith.) 



Fig. 370. 




Circular amputation at the elbow. 
(Smith.) 



Circular Method. 

An incision dividing the skin and cellular tissue is made 
around the limb three inches below the line of the condyles 
of the humerus (Fig. 368, (7), the skin is dissected up and 
a circular incision made through the muscles, the joint is 
opened and the disarticulation effected. (Fig. 370.) 



450 AMPUTATIONS, 



Amputations of the Arm. 

The arm may be removed at any point below the attach- 
ment of the muscles at the axilla, by either the circular, 
flap, oval, or modified circular methods. 

Circular Method. 

This operation is usually employed in removing the arm 
in its lower third : a circular incision of the skin and muscles 

Fig. 371. 




Circular amputation of the arm. 

is first made, and when the cuff has been dissected up, a 
circular division of the muscles is made, and after applying 
the retractor the bone is sawed through. (Fig. 371.) 

Flap Method. 

From the central position of the bone in the arm the 
flap method in amputating the arm is preferred by many 
operators. The arm being grasped by the hand the point 
of a medium-sized amputating knife is thrust through the 
arm so as to pass over the humerus and make its exit at a 
corresponding point in the skin on the opposite side ; a flap 
of sufficient length is cut from within outward. The knife 
is next passed behind the bone and a posterior flap is cut in 



AMPUTATIONS OF THE ARM. 451 

the same manner (Fig. 372) ; the bone is next cleared of 
muscular tissue and the flaps are retracted and it is divided 
with a saw. 

Fig. 372. 




Amputation of the arm by flap operation. (Bktant.) 

Lateral flaps may be made in this amputation in the place 
of the antero-posterior flaps, and they are cut from within 
outward in the same manner. 

Oval, or Modified Oval Method. 

This method of amputating the arm is also employed with 
advantage. An oval flap of skin and cellular tissue is made 
and dissected up, and the muscular tissue is divided by a 
circular incision. Or two oval flaps of skin and cellular 
tissue are cut and dissected up, and the muscles are next 
divided by a circular sweep of the knife. 

In all amputations of the arm it is well to remember the 
possibility of a high division of the brachial artery, and to 
see that the abnormal vessel is properly secured, if present. 

In high amputations of the arm there is sometimes not 
room enough to apply Esmarch's strap or a tourniquet to 
the arm itself to control the hemorrhage during the opera- 
tion, and in such cases the strap may be passed from the 
axilla around the outer end of the clavicle, as is done to 
control the bleeding during amputation at the shoulder-joint. 
(Fig. 373). 



452 



AMPUTATIONS 

Fig. 373. 




Esmarch's strap applied in high amputation of the arm. (Smith.) 

Amputations at the Shoulder-joint. 

Several methods of operation are employed in amputating 
at the shoulder-joint, such as the oval method, or Larrey's 
method, flap method, Lisfranc's or Dupuytren's method, and 

Fig. 374. 




Amputation at the shoulder-joint. A. Oval, or Larrey's method. 
B. Double-flap, or Lisfranc's method. (Stimson.) 



AMPUTATIONS AT THE SHOULDER-JOINT. 453 

Spence's method. (Fig. 374.) The control of the bleeding 
from the axillary artery during the operation is a matter of 
the first importance, and it may be arrested by pressure made 
upon the subclavian artery, as it crosses the first rib, with 
the thumb, or the padded handle of a large key, or by the 
fingers of an assistant grasping the axillary flap and com- 
pressing the vessel after the head of the bone has been dis- 
articulated, or by the use of an elastic strap applied around 
the axilla and shoulder. (Fig. 373.) 

Oval, or Larrey's Method. 

In this method of amputation the point of the knife is 
entered just below the acromion process, and a deep incision 




Amputation at the shoulder-joint by Larrey's method. 



three inches in length is made down to the head of the bone 
in the axis of the arm ; from the middle of this incision two 

20* 



454 



AMPUTATIONS. 



others are made obliquely downward to the points where the 
anterior and posterior folds of the axilla end in the tissues 
of the arm : the latter incision should be only deep enough 
to divide the skin and superficial fascia. The flaps are then 
dissected up until the head of the bone is well exposed, and, 
after opening the capsule and dividing the muscles inserted 
into the neck and tuberosities of the humerus, which division 
may be facilitated by rotating the head of the bone outward 
and inward, the disarticulation is effected by adducting the 
elbow ; the knife is next passed downward behind the bone 
and made to cut outward in the line of the cutaneous incis- 
ions — an assistant controlling the artery before it is divided, 
by grasping the axillary tissues behind the knife with his 
fingers. 

Flap, or Dupuytreri 's Method. 

In this method of amputation at the shoulder -joint the 
flaps may be cut either by transfixion, or from without in- 



Fig. 37 




Amputation at the shoulder-joint, Dupuytren's method. (Bryant.) 



ward ; the large flap embraces the greater part of the 
deltoid muscle, and the smaller or short flap is cut from the 
inside of the arm after the head of the bone has been dis- 
articulated. When cut by transfixion, the point of the knife 



AMPUTATIONS AT THE S HOU LDE R- JOINT , 



455 



should be entered an inch in front of the acromion process 
and pushed across the outer aspect of the head of the 
humerus, and should be brought out at the posterior fold of 
the axilla ; the knife is made to cut downward until a large 
deltoid flap is formed. This flap is turned up, and the head 
of the bone is disarticulated ; the knife being placed behind 
it, a short flap is cut out, keeping close to the bone so that 
the vessel is divided with the last cut of the knife. (Fig. 
376.) An assistant should control the vessel by grasping 
the axillary tissues with his fingers behind the knife. 

Double Flap, or Lisfrancs Method. 

In this method of amputation at the shoulder-joint the 
point of the knife is entered at the outer side of the cora- 
coid process, and is carried across the outer aspect of the 
head of the humerus and brought out a little below the 
posterior border of the acromion process, and a long flap is 
cut downward. This flap is turned up 
and the attachments of the head of the FlG - 377 - 

bone are divided and it is disarticu- 
lated. The knife is again entered 
behind the bone, and a long posterior 
flap is cut from within outward. (Fig. 
374, B) 

Spenee's Method. 

In this method of amputation at 
the shoulder-joint an incision is made 
down to the head of the humerus 
immediately in front of the coracoid 
process, and is continued downward 
through the clavicular fibres of the 
deltoid and pectoralis major muscles 
until the attachment of the latter to 
the humerus is reached. (Fig. 377.) 
The incision is now carried backward 
to the posterior fold of the axilla. A 
second incision, including only the skin and cellular tissue, 
is next made from the anterior portion of the first incision 




Amputation at the 
shoulder-joint. Spenee's 
method. (Stimson.) 



456 AMPUTATIONS. 

across the inside of the arm to meet the incision on the outer 
part. The outer flap thus formed is turned up and the 
head of the bone is disarticulated, and the operation is com- 
pleted by dividing the remaining tissues on the axillary 
aspect. 

Many other methods of removing the arm at the shoulder- 
joint have been devised and employed, including the circular 
method. 

Amputation above the Shoulder- joint. 

This form of amputation consists in the removal of the arm 
with a part or the whole of the scapula and sometimes a 
portion of the clavicle. 

As this form of amputation is required in cases in which 
the laceration of the parts has passed beyond the shoulder- 
joint, or in cases of growths involving the tissues beyond 
the joint, no definite rule can be laid down for the incisions ; 
the only rule being as far as possible to make the incisions 
in such a manner that the least possible amount of skin is 
sacrificed, so that a sufficient covering for the wound can 
be obtained. 

Amputations of the Foot. 

Amputations of the Toes. 

The phalanges of the toes may be removed in the same 
manner as those of the fingers. It is better to amputate at 
the metatarso-phalangeal articulations than to attempt to 
remove them at the joints in front of this articulation, ex- 
cept in the case of the great toe, as the preservation of a 
portion of a toe is rather a discomfort than an advantage, 
except in the instance mentioned. All incisions should be 
made so that the resulting cicatrix does not occupy the 
plantar surface, and it is well to remember that the web of 
the toes is considerably below the position of the metatarso- 
phalangeal joint. (Fig. 378.) 

The toes are usually removed by an incision on the dorsal 



AMPUTATIONS OF THE TOES, 



457 



surface a little above the joint, which is carried down the 
bone for about an inch and then diverges into the web, and 



Fig. 378. 



Fig. 379. 




Relations of web and metarso- 

phalangeal joint of toes. 

(Stimsox.) 




Incisions for amputation of toes 

and metatarsal bones. 

(Stimsox.) 



is carried under the toe and back on the other side to the 
point of divergence. (Fig. 378.) 

Amputation of Two Adjoining Toes. 

The dorsal incision should be made in the inter-metatarsal 
space just above the level of the joint (Fig. 379, B) and 
carried down to the beginnino; of the web ; then over the 
toe to the beginning of the adjoining web, and under the 



458 



AMPUTATIONS. 



plantar surface of both toes in the line of the digito-plantar 
fold, through the web and back to the point of divergence. 

Amputation of the Great Toe. 

This may be accomplished by means of the racket-shaped 
incision employed in amputation of the other toes or by 
means of a lateral flap. In the latter case the knife is made 
to enter the joint by cutting through the commissure, and 
the operation is completed by carrying the knife through 
the joint and along the outer or inner side of the bone, 
forming a flap of the required size. (Fig. 380.) 

In this amputation a short dorsal flap and long plantar 
flap may be employed, or a long internal flap may be used. 

Amputation of All the Toes. 

To amputate all the toes, make a dorsal incision from 
the head of the fifth to the head of the first metatarsal 



Fig. 380. 



Fig. 381. 





Amputation of the great toe. 
(Smith.) 



Incision for amputation of 
all the toes. (Smith.) 



bone ; the incision should be a curved one passing just in 
front of the joints. (Fig. 381.) Dissect up the flap and 
open the joints, dividing the lateral ligaments, and pass the 



AMPUTATION OF METATARSAL BONES. 459 

knife behind the phalanges and cut a flap from the plantar 
surface. 

Amputation of the Metatarsal Bones. 

It is better in these amputations to leave the tarsal head 
of the metatarsal bone in place and divide the bone, or in 
other words to do an amputation in continuity to prevent 
opening up the tarsal articulations. 

Amputation of the Metatarsal Bone of the Great Toe. 

The incision begins upon the dorsal surface of the meta- 
tarsal bone, a little below the point at which the bone is to 
be divided, and is carried down below the metatarso-phalan- 

Fig. 382. 




Amputation of the great toe and first metatarsal bone. (Smith.) 



geal joint, then diverges and passes under the toe and comes 
back again to the point of divergence. (Fig. 379, 0.) The 
bone is exposed and cut through with cutting forceps and 
is then lifted up and dissected loose from the tissues. (Fig. 
382.) 



460 AMPUTATIONS. 

Amputation of the Fifth Metatarsal Bone. 

The incision for the removal of the fifth metatarsal bone 
is made over the bone a little below the metatarso-tarsal 
articulation, and is carried down and curved around the toe 
(Fig. 379, D), and after the bone is exposed by dissecting 
back the flaps, it is divided, or the joint is opened and it is 
dissected out. 

Amputation Through the Metatarsal Bones. 

In performing this amputation an incision is made across 
the dorsum of the foot and a short dorsal flap is dissected 
up ; the metatarsal bones are next divided with a saw and a 
long plantar flap is cut from within outward by entering the 
knife behind the ends of the bones. 

Tarso-metatarsal Amputations. 

In all amputations of the foot involving the tarsus the 
surgeon should be thoroughly familiar with the anatomy of 
the foot and the surgical landmarks of the diiferent articu- 
lations. I shall refer to those laid down by Mr. Bryant, 
which are as follows : 

" On the inner side of the foot not far from the inner 
malleolus the tubercle of the scaphoid (Fig. 383, A), is to 
be felt as a marked prominence ; about one-half an inch in 
front of this will be found the articulation with the cunei- 
form bone (i?), and one inch in front of this the joint which 
the surgeon will have to open in Lisfranc's or Hey's opera- 
tion (0); just above the tubercle of the scaphoid will be 
found the articulation with the astragalus, the line of Cho- 
part's amputation (D). On the outer side of the foot, one 
inch below the external malleolus, a sharply defined projec- 
tion will always be felt, which is the peroneal tubercle (E), 
one-half an inch in front of this will be found the joint 
which separates the os calcis from the cuboid (J 7 ), this joint 
forming the outer circle to Chopart's amputation. Half 
an inch in front again or one inch from the tubercle, the 



AMPUTATIONS OF THE FOOT 



461 



prominence of the fifth metatarsal bone is always to be felt 
(H), the line above this prominence indicating the articula- 



Fig. 3S3. 




Surgical guides to the foot 
as expressed by anatomy. 
(Bbyant.) 



Fig. 384. 




Incision for — A. Lisfranc' 
amputation. B. Chopart' 
amputation. (Stimson.) 



tion with the cuboid bone, which forms the outer boundary 
of the incision for Hey's or Lisfranc's amputations. 

Tar so- metatarsal Amputation [Lisfranc 's). 

The incision for this amputation is a curved one carried 
across the dorsum of the foot from the base of the fifth to 
the base of the first metatarsal bone. (Fig. 384, A.) The 
incision should involve the skin only, its centre lying half 



462 AMPUTATIONS. 

an inch or more below the centre of the line of the articu- 
lations, and it should begin and end at the sides of the foot 
at their junction with the sole. A plantar flap should be 
marked out by a curved incision crossing the sole of the 
foot near the origin of the toes, starting and ending at the 
same points as the dorsal incision. 

The dorsal flap is next dissected back to the line of the 
articulations ; the tendons, muscular fibres, and fascia being 
divided, the joints between the tarsal and metatarsal bones 
are opened with a stout, narrow-bladed knife. (Fig. 385.) 

Fig. 385. 




Amputation at tarso-metatarsal joint (Lisfranc's). (Skey.) 

Difficulty is sometimes experienced in opening the joint be- 
tween the head of second metatarsal bone and the second 
cuneiform bone, which occupies a position higher on the 
foot than the other articulations. The disarticulation may 
also be facilitated by forcibly depressing the anterior por- 
tion of the foot. After the joints have all been opened, the 
knife is passed behind the ends of the metatarsal bones and 
a plantar flap is cut from within outward, following the line 
of the incision previously marked out. The plantar flap 
may be cut from without inward if preferred. 



AMPUTATIONS OF THE FOOT. 



463 



Tarso-metatarsal Amputation (Hey's). 

The line of incision and the steps of this operation are 
similar to those in Lisfranc's amputation, with the excep- 
tion that Hey sawed off the projecting portion of the 
internal cuneiform bone after disarticulating the metatarsal 
bones. This modification, although it improves the appear- 
ance of the stump, possesses no advantages over the previous 
procedure. 

Medio-tarsah or Chopart's Amputation. 

In this amputation the disarticulation is through the joints 
formed by the astragalus and calcaneum behind and the 
scaphoid and cuboid in front. An incision is made from 

Fig. 386. 




Line of incision for — A. Chopart's amputation. B. Syrne's amputation. 
C. Section of bone in Syme's amputation. D. Subastragaloid amputation. 

(3TIM30N-.) 



the tubercle of the scaphoid across the dorsum of the foot 
an inch in front of the head of the astragalus to the lower 
and outer border of the cuboid. (Fig. 386, A.) The plan- 
tar flap is next marked out by an incision beginning and 
ending at the same points as the first incision and crossing 



464 AMPUTATIONS. 

the sole of the foot four or five finger-breadths nearer the 
toes. The dorsal flap is next dissected up, and after the 
tendons and fascia have been divided the joint is opened 




Chopart's amputation. (Bryant.) 

and a plantar flap is cut from within outward following the 
line of the previously marked out plantar incision. (Fig. 
387.) 

Subastragaloid Amputation. 

In this amputation all the bones of the foot are removed 
except the astragalus. An incision is made beginning an 
inch below the tip of the external malleolus which is car- 
ried forward to the base of the fifth metatarsal bone ; it is 
then carried over the dorsum of the foot to the calcaneo- 
cuboid articulation. (Fig. 386, D.) The joints between 
the scaphoid and astragalus and between the astragalus 
and calcis are opened, and the latter bone is carefully dis- 
sected out ; the ligaments are divided and the astragalus 
only is allowed to remain in place. 

Amputations at the Ankle-joint. 

Syrnes Amputation at the Ankle-joint. 

In this amputation, the foot being at a right angle to the 
leg, an incision is made from the centre of one malleolus 



AMPUTATIONS AT THE ANKLE-JOINT. 465 

directly across the sole of the foot to the centre of the oppo- 
site malleolus. (Fig. 386, B ) The tissues of the heel are 
next carefully dissected from the bone by keeping the knife 
close to the osseous surface until the tuberosity of the os 
calcis is fairly turned. The two extremities of the first 
incision are then joined by a transverse one across the in- 
step, and, the joint being opened, the lateral ligaments are 
divided to complete the disarticulation. (Fig. 388.) The 



Fig. 388. 




Syme's amputation at the ankle-joint. (Pkey.) 

knife is next used to clear the malleoli, and they are next 
removed by the saw in the line indicated. (Fig. 386, C.) 

Pirogoff's Amputation at the Ankle-joint. 

In this amputation the posterior portion of the os calcis 
is retained. The incision is carried from the tip of the 
inner malleolus, over the instep, half an inch in front of 
the anterior edge of the tibia, to a point half an inch in 



466 



AMPUTATIONS. 



front of the tip of the outer malleolus ; a second incision, 
crossing the sole of the foot and carried down to the bone, 



Fig. 389. 




Pirogoff's amputation. A, cutaneous incision. B, line of section of bones. 

(Stimson.) 

is next made. (Fig. 389, J..) The plantar flap is dissected 
back for a quarter of an inch, the joint is opened by dividing 

Fig. 390. 




Application of saw to calcis in Pirogoff's amputation. (Erichsen.) 



AMPUTATIONS AT THE ANKLE-JOINT. 467 



the lateral ligaments, and the astragalus is disarticulated, 
and the malleoli are exposed. A narrow saw is next applied 
to the upper and posterior part of the calcaneum behind the 
astragalus, and it is divided obliquely downward in the line 
of the plantar incision. (Fig. 39(3.) The malleoli and a thin 
slice of the tibia are next removed with the saw as in Syme's 
amputation. (Fig. 386, C.) Some surgeons do not remove 
the malleoli, but press the sawed sur- 
face of the os calcis between them FiG - 39L 
when it is possible to do so. The 
position of the os calcis in relation 
to the tibia after union has occurred, 
is shown in Fig. 391. 

Rouxs Amputation at the 
Ankle-joint. 




wmm 




Union between calca- 
neum and tibia in Piro- 
goff's amputation. (Hew- 
sox.) 



In this method of amputation an 
incision is made at the outer edge of 
the tendo Achillis, a little above its 
insertion, which is carried forward 
under the outer malleolus, and across 
the instep half an inch in front of 
the anterior edge of the tibia, and 
back to a point just in front of the 
inner malleolus ; the incision is car- 
ried from this point downward and 
partly across the sole of the foot, 
and then back to the point of origin of the original incision. 
(Fig. 392.) The flaps are dissected up for a short distance, 
the ankle-joint is then opened, and the disarticulation is 
effected, and the internal flap is carefully dissected from the 
bones. 

Other methods of amputation of the foot are sometimes 
emloyed ; such, for instance, as that advocated by Hancock, 
who has combined Pirogoff's amputation with the subastrag- 
aloid method, bringing the sawed surface of the os calcis in 
contact with a transverse section of the astragalus. 

Hancock has advocated the propriety of amputating in the 
foot without regard to the position of the tarsal joints, cutting 



468 AMPUTATIONS. 

the flaps of sufficient length and dividing the bones with a 
saw. 

Tripier has also modified the subastragaloid amputation 
by leaving the upper part of the calcaneum, which he saws 
through on a level with the sustenaculum tali, and at right 
angles to the axis of the leg ; the external incisions are made 
as in Chopart's amputation. 

Fig. 392. 




Incisions in Eoux's amputation. 

In the method advocated by Mikulicz the astragalus and 
calcaneum are removed, the ends of the tibia and fibula are 
sawed off, and the sawed surface of the scaphoid and cuboid 
are approximated to these, the stump resulting resembling 
the foot of pes equinus. 

Amputations of the Leg. 

The leg may be amputated at its lower, middle, or upper 
third, the rule being to save as much of the limb as possible, 
but as regards the application of prothetic apparatus, I 
think the stumps resulting from amputations in the middle 
and upper thirds will be found more satisfactory. It is well 
also in sawing the bones to divide the fibula at a slightly 
higher point than the tibia. 



AMPUTATIONS OF THE LEG. 469 



Amputation at the Lower Third of the Leg. 

At this position the leg may be amputated by the circular, 
modified circular, or elliptical method. 

Circular Method. 

A circular incision is made through the skin and con- 
nective tissue just above the malleoli and the cuff is dissected 
up for a sufficient distance, and a circular incision of the 
tendons and muscles is next made and the tissues being 
retracted the bones are divided with a saw. 

Modified Circular Method. 

In this method of amputation of the leg a circular in- 
cision of the skin and connective tissue and two short lateral 
incisions are made and the flaps are dissected up to the end 
of the incisions, and a circular division of the muscles is 
next made. (Fig. 393, A.) Or oval skin flaps are made 
and dissected up, and the tissues are next divided down to 
the bone by a circular incision and the bones are divided 
with a saw. (Fig. 395.) 

Elliptical Method. 

In this method of amputation the incision is in the form 
of an ellipse, its lower end crosses the heel below the inser- 
tion of the tendo Achillis and the upper end of the incision 
is about an inch above the anterior articular edge of the tibia. 
(Fig. 394, B.) 

Long Anterior Flap Method. 

An anterior flap equal in length to the diameter of the 
leg at its base is marked out by a curved incision through 
the skin beginning at the posterior edge of the tibia on the 
inner side, a little below the point at which the bones are 
to be divided, and is carried over the leg to a point directly 

21 



470 



AMPUTATIONS. 



opposite over the fibula. (Fig. 394, A.) The anterior 
muscles are divided transversely half an inch above the 



Fig. 393. 



Fig. 394. 




Amputation of the leg. A. 
Modified, circular method. B. 
Eectangular flap. C. Antero- 
posterior flaps. (Stimson.) 




Amputation of the leg. A. 
Long anterior flap. B. Supra- 
malleolar long posterior flap. 
C. At upper third. (Stimson.) 



AMPUTATIONS OF THE LEG. 471 

lower end of the flap and are dissected from the bones to 
the base of the flap. 

Fig. 395. 




Oval skin flaps with circular division of the muscles. 

The posterior flap is then made by entering the knife 
behind the bones at the point of the original incision and 
cutting directly outward. 

Long Anterior Rectangular Flap Method. (Teale.) 

In this method of amputation of the leg an incision equal 
in length to half of the circumference of the leg is made 
from the point at which the bones are to be divided on one 
side of the leg and is carried across the limb and back 
upon the opposite side to a point opposite the point of 
starting. The flap thus marked out is dissected up to its 
base and a posterior flap one-fourth the length is next cut 
by a transverse incision down to the bones and is dissected 
back to the line of the origin of the first incision. (Fig. 
393, B.) The long flap is next doubled back and its edges 
secured to the posterior flap, or the long flap may be cut 
from the posterior surface of the leg and the short flap from 
the anterior surface. 

Antero-posterior Flap Method. 

A long anterior flap including half of the circumference 
of the limb may be cut from without inward, composed of 
skin, connective tissue, and muscles, and a short posterior 
flap cut from within outward may also be employed. This 
method is often employed in amputations in the upper por- 
tion of the leg. (Fig. 393, C.) 



472 AMPUTATIONS. 

Lateral Flap Method. 

In the lower and middle thirds of the leg the method of 
amputation by means of lateral skin flaps may be employed 
with advantage. In this method an incision is made over 
the spine of the tibia and an oval flap, embracing one-half 
of the circumference of the leg, composed of the skin and 
connective tissue, is dissected up ; starting from the same 
point a similar flap is cut upon the opposite side of the leg 
and dissected up ; the muscles at the upper extremity of 
the flaps are next divided by a circular incision and the 
bones are divided with a saw. 

External Flap Method.' (Sedillot.) 

In this method of amputation of the leg the point of the 
knife is entered a finger's breadth external to the spine of the 
tibia and carried outward, grazing the fibula and is brought 
out as far as possible to the inner side ; a flap three or four 
inches in length is then cut from within outward ; the ex- 
tremities of the incision are next united by an incision 
across the inner side of the limb involving the skin only ; 
any remaining muscular tissue is next divided and the bones 
are sawed, and the long external flap is brought over the 
ends of the bones and fastened to the edges of the incision 
on the inner side of the limb. Prof. Ashhurst modifies this 
operation by cutting the long external flap from without 
inward, and makes also a short internal flap in the same 
manner. By either method the resulting stump is a good 
one, with the ends of the bone covered by the tissues of the 
external flap. 

Amputations at the Knee-joint. 

Amputations at the knee-joint may be done either by the 
circular or elliptical incision or by means of flaps, and may 
consist in simple disarticulations or sections through the 
condyles of the femur. 



AMPUTATIONS AT THE KNEE-JOINT. 473 



Elliptical or Oval Method. 

In this operation an incision crossing the spine of the 
tibia five finger-breadths below the lower extremity of the 
patella is carried around the back of the leg three finger- 
breadths higher than in front ; the tissues on the front of 
the leg are dissected up until the tendon of the patella is 
exposed ; the leg is then flexed and the ligament of the 
patella is divided ; the capsular ligament and the lateral 
and crucial ligaments are next divided, care being taken 
not to injure the popliteal vessels with the point of the 
knife. The tibia is next drawn forward and the knife is 
passed behind its posterior border, and the remaining soft 
parts are divided from within outward. 

Anterior Flap Method. 

In this method of amputation a long cutaneous flap is 
formed ; the incision beginning half an inch below the 
articulation is carried five inches below the patella; cross- 
ing the anterior surface of the leg it is carried back to the 
condyle of the femur on the opposite side. This flap is 
dissected up and the ligament of the patella is divided, and 
the disarticulation is effected. A short posterior flap, uniting 
the anterior incision one inch below its extremities, is next 
cut by transfixion or from without inward. (Fig. 396, A.) 

Amputation through the Condyles of the Femur. 

In this amputation, which is known as Garden's amputa- 
tion, an anterior flap, whose lower extremity is three finger- 
breadths below the patella, is cut and the disarticulation is 
effected, and the posterior soft parts are divided. The 
patella is removed and the condyles next sawed through 
just above the edge of the articular cartilage. (Fig. 396, B.) 

Lateral Flap Method. 

In this operation an incision is made just below the 
patella, which is carried down the spine of the tibia for 



474 AMPUTATIONS. 

Fig. 396. Fig. 397. 




Amputations at the knee-joint 
and lower third of thigh. A. 
Long anterior flap. B. Ampu- 
tation through condyles. (7 
Modified flap at lower third of 
thigh. (Stimson.) 




Amputation at knee-joint by la f eral 
flaps. (SmithO 



three inches, and is then carried 
backward to the middle of the 
leg to a point opposite the be- 
ginning of the incision ; a simi- 
lar flap is cut on the opposite 
side of the leg, and the flaps are 
dissected up to the line of the 
articulation, and when this point 
is reached the joint is opened 
and the disarticulation is effected. 
The patella is not removed. (Fig. 
397.) 

Gritti 's Amputation at the Knee- 
joint. 



In this operation a long rec- 
tangular anterior flap is first 
cut and dissected up, and after 
the disarticulation has been effected the skin covering the 
posterior surface of the knee is cut from within outward. 
The condyles of the femur are next removed by a saw above 
the edge of the articular cartilage, and the articular surface 
of the patella is removed by the saw or cutting forceps. 
The patella is next brought down so that its sawed surface 



AMPUTATIONS OF THE THIGH. 475 

is in contact with the sawed surface of the condyles, and the 
flaps are brought together. (Fig. 398, A.) 



Amputations of the Thigh. 

Modified Flap Method. 

Two semilunar flaps of skin and connective tissue, the 
upper extremity of which are several inches above the con- 
dyles of the femur, are cut and dissected up, and the muscles 
are next divided by a circular incision, and the bone is cut 
through with the saw. (Fig. 396, C.) 

Long Anterior Flap Method. 

In this operation an incision is made on the anterior 
aspect of the thigh, marking out a flap whose length is 
equal to one-third, and whose width at its base is equal to 
two-thirds, of the circumference of the limb. The anterior 
muscles are next divided obliquely upward and backward, 
so that the flap shall not be too thick, and the posterior 
muscles are cut transversely and the bone is divided with a 
saw. (Fig. 398, B.) 

Amputation in the lower third of the thigh may also be 
effected by employing a long anterior and short posterior 
flap. The anterior flap is cut, its lower extremity extending 
down to the lower edge of the patella, and after dissecting up 
the skin and cellular tissues to the upper extremity of the 
patella, the muscles are cut obliquely up to the point at 
which the bone is to be divided. A short posterior flap is 
next cut, and the soft parts being retracted, the bone is sawed 
through. (Fig. 398, C.) 

Amputation of the Thigh by Transfixion. 

In amputations of the thigh the flaps may also be cut by 
transfixion, either lateral or antero-posterior flaps being em- 
ployed. (Fig. 399.) 



476 



AMPUTATIONS. 
Fig. 




A. Gritti's amputation at the knee. A'. Lines of division of the bones. 

B. Amputation of the thigh, long anterior flap. B' . Division of the bone. 

C. Amputation at the lower third of the thigh. C , Division of the bone 

D. Disarticulation at the hip-joint. 

Amputation of the Thigh through the Trochanters. 

When, for any reason, it is inadvisable to amputate at the 
hip-joint, an amputation may be made through the trochan- 
ters, a long anterior and short posterior flap being employed 
with a circular division of the muscles. 



AUPUTATIONS AT THE HIP-JOINT. 477 

Fig. 399. 




Amputation of thigh by flaps cut by transfixion. 



Amputations at the Hip-joint. 



In amputations at the hip-joint it is important that pro- 
vision be made for the control of hemorrhage during the 



Fig. 400. 




Abdominal tourniquet. 
21* 



478 AMPUTATIONS. 

operation, and this is accomplished by the use of an abdomi- 
nal tourniquet (Fig. 400), or by the use of Davy's lever 
making compression upon the common iliac artery from the 
rectum, or by compression of the femoral artery by the 
fingers of an assistant, or by the preliminary ligation of the 
femoral artery just below Poupart's ligament. Esmarch's 

Fig. 401. 




Esmarch's elastic strap applied to control hemorrhage during 
amputation at the hip-joint. 

elastic strap may also be employed for the control of bleed- 
ing during amputation at the hip-joint, the strap being ap- 
plied in such a manner that it occupies the position of the 
turns of a spica bandage of the groin. (Fig. 401.) 

The most satisfactory method of controlling the bleeding 
during amputation at the hip-joint, or at the trochanters, is 
that recommended by Wyeth, which consists in the use of 
two stout steel pins twelve inches in length, and a piece of 
rubber tubing one-half of an inch in diameter and five or six 
yards in length. The point of one pin is inserted into the 
tissues one and a half inches below the anterior spine of the 
ilium, and is passed through the tissues external to the neck 
of the femur, and its point is made to project from the skin 



AMPUTATIONS AT THE HIP-JOINT. 479 

just back of the great trochanter ; the second pin is passed 
through the skin an inch below the level of the groin in- 
ternal to the saphenous opening, and is carried through the 
adductor muscles and its point made to emerge half an 
inch in front of the tuberosity of the ischium ; the rubber 
tubing is next wound around the thigh above the pins and 
securely tied. 

The methods of amputation at the hip-joint are the oval, 
ant ero-posterior flap, and lateral flap, and modified circular 
methods. 

Oval Method. 

This is performed by entering the point of a strong knife 
into the tissues below the anterior superior spinous process 
of the ilium and making two oblique incisions, one forward 
and downward and the other backward, both incisions meet- 
ing on a transverse line on the inner side of the thigh. The 
muscles are next divided on a little higher line, and when 
the joint is exposed disarticulation is effected from the out- 
side and any remaining tissue is divided. 

Anfero posterior Flap Method. 

In this method the point of a long amputating knife is 
thrust into the tissues about two finger-breadths below the 
anterior superior spinous process of the ilium, and is 
pushed through the tissues grazing the hip-joint and is 
Drought out on the opposite of the thigh close to the junc- 
tion of the scrotum. The knife is next carried downward 
close to the bone and an anterior flap of sufficient length is 
cut from within outward. This flap is held up by an assist- 
ant and the head of the bone is disarticulated, and the knife 
being passed behind the bone, a posterior flap of equal length 
is cut from within outward. (Fig. 402.) 

Guthrie 8 method of amputation at the hip-joint consists 
in cutting the flaps from without inward, a smaller knife 
being used for this purpose and the posterior flap being cut 
first. 



4:80 



AMPUTATIONS. 

Fig. 402. 




Amputation at the hip-joint by antero-posterior flaps. (Holmes.) 

Modified Circular Method. 

In this operation short antero-posterior flaps of skin and 
connective tissue are cut and dissected up, and the muscles 

Fig. 403. 




Amputation at the hip-joint by external and internal flaps. (Bryant.) 



AMPUTATIONS AT THE HIP-JOINT. £81 

are divided by a circular incision on the level of the joint, 
and the disarticulation of the head of the femur is next 
effected. 

Lateral Flap Method. 

In this operation two flaps are cut from the inner and 
outer side of the thigh by transfixion, or by cutting from 
without inward and exposing the joint, which is opened and 
the disarticulation of the head of the femur is effected as in 
the previous methods. (Fig. 403.) 



INDEX. 



ABDOMINAL aorta, ligation of, 
413 

bandage, 28 
Abscess, acute. 263 

cbronic. 264 

cold. 261 

deep-seated, opening of, 263 

dressing of, 263 

opening of, 263 

sinuses from, 265 
Absorbent cotton, 131 
A. C. E. ana?sthetic mixture, 202 
Acromion process of scapula, fracture 

of, 320 
Actual cautery, 155 
Acupressure, 251 

first method of, 254 

second method of, 251 

third method of, 255 

fourth method of. 255 

fifth method of. 255 

sixth method of, 256 

seventh method of, 256 
Acupuncture. 152 

needles, 152 
Acute abscess, 263 
Adhesive plaster. 131 
Agnew's splint for fracture of patella, 

346 
American bandage of foot. 72 
Amputating knives, 133. 131 

saws, 131 
Amputation or amputations, 425 

at ankle-joint. 161 

Pirogoff s, 165 
Roux's. 407 
Byrne's, 164 

of arm. 450 

circular. 420 

details of, 438 

at elbow, 44-5 

elliptical, 431 

of fingers, 441 

metacarpophalangeal, 443 



Amputations, flap, 429 
of foot. 460 

Hancock's. 467 

Hey's, 463 

Lisfranc's, 161 

Mikulicz's, 46S 

Tripier's, 467 
of forearm, J 47 
of hand, 441 

carpo-meta carpal, 446 
at hip-joint, 477 et seq. 

Guthrie's. 479 
instruments for, 433 
at knee-joint, 472 

Carden's, 473 
Gritti's, 474 
of leg, 468 et seq. 

Sedillot's, 472 
medio-tarsal, 463 
of metacarpal bones, 445 
of metatarsal bones, 459 
methods of, 428 
modified circular. 431 
oval, 431 

periosteal flaps in, 433 
by rectangular flaps, 432 
re-dressing of, 440 
above shoulder-joint, 456 
at shoulder-joint, 452 et seq. 

Dupuytren's, 454 

Larrey's, 453 

Lisfranc's, 455 

Spenee's, 455 
subastragaloid, 464 
sutures in, 437 
tarso-metatarsal. 460 

Hey's, 403 

Lisfranc's, 461 
Teale's method. 432 
of thigh, 475 et seq. 
of toes, 456 
at wrist, 446 
Anaesthesia from cocaine, 193 
from cold, 192 



484 



INDEX. 



Anaesthesia, local, 192 

from nitrous oxide gas, 194 
from rapid respiration, 193 
from rhigolene, 192 

Anesthetic mixture, A. C. E., 202 

Anaesthetics, 192 

in tracheotomy, 279 

Aneurism needle, 394 

Ankle-joint, amputations at, 464 
Pirogoffs, 465 
Eoux's, 467 
Syme's, 464 
dislocations of, 387 

Anterior tibial artery, ligation of, 
422 

Antisepsis, 99 

Antiseptic bandages, 118 

dressings, improvised, 118 
gauze, 115 
poultice, 142 

Aorta, abdominal ligation of, 413 
compressor, Lister's, 245 

Aqua ammonia, 149, 151 

Aristol, 108 

Arm, amputations of, 450 

Arterial hemorrhage, 241 

control of, permanent, 249 
temporary, 241 
transfusion, 167 

Arteriotomy, 164 

Artery or arteries — 

anterior tibial, ligation of, 422 
axillary, ligation of, 405 
brachial, ligation of, 407 
common carotid, ligation of, 399 

iliac, ligation of, 413 
dorsalis pedis, ligation of, 424 
external carotid, ligation of, 401 

iliac, ligation of, 416 
facial, ligation of, 404 
femoral, ligation of, 418 et seq. 
forceps for, 436 
gluteal, ligation of, 417 
inferior thyroid, ligation of, 399 
innominate, ligation of, 395 
internal carotid, ligation of, 402 
iliac, ligation of, 415 
pudic, ligation of, 417 
interosseous, ligation of, 413 
ligation of, 393 et seq. 
lingual, ligation of, 403 
occipital, ligation of, 404 
popliteal, ligation of, 421 
posterior tibial, ligation of, 424 
radial, ligation of, 409 
sciatic, ligation of, 417 



Artery, subclavian, ligation of, 396 
superior thyroid, ligation of, 403 
temporal, ligation of, 404 
ulnar, ligation of, 411 
vertebral, ligation of, 398 
wounded, ligation of, 258 
Artificial respiration, 170 

direct method of, 171 
Howard's method of, 171 
Marshall Hall's method of, 

175 
Sylvester's method of, 174 
Asepsis, 99 

Aseptic operation, details of, 122 
preparation for, J 20 
surgery, materials used in, pre- 
paration of, 109 
Aspiration, 177 
Aspirator, 177 
Astragalus, dislocation of, 388 

fracture of, 355 
Auto-transfusion, 168 
Axillary artery, ligation of, 405 



BACILLUS pyocyaneus, 100 
pyogenes foetidus, 100 
Bandage or bandages — 
abdominal, 28 
antiseptic, 118 
Barton's, 32 

modified, 33 
of chest, anterior figure-of-eight, 
60 
posterior figure-of-eight, 60 
circular, 19, 22 
compound, 23 
crossed, of eye, 41 

of both eyes, 42 
demi -gauntlet, 48 
Desault's, 56 
dimensions of, 17 
Esmarch's, 247 
figure-of-eight, 22 

of elbow, 51 
of knee, 68 
of both knees, 69 
of leg, 75 

of neck and axilla, 54 
of foot, American, 72 
covering heel, 72 
not covering heel, 73 
French, 73 
spica, 71 
four-tailed, of chin, 27 
of head, 27 



INDEX 



485 



Bandage, gauntlet, 46 
Gibson's, 34 

glue and oxide of zinc, 96 
gum and chalk, 95 
handkerchief, 28 

cord, 29 

cravat, 29 

oblong, 28 

square, 28 

triangle, 29 
for hands and feet, 78 
of head, 32 

and neck, 40 

oblique, 44 
Liebreich's, 78 
of lower extremity, 65 
many-tailed, 26 et seq. 
of neck, 32 
oblique, 19 

of angle of jaw, 36 
occipito-facial, 43 
paraffin, 96 
plaster-of- Paris, 83 

application of, 84 

preparation of, 84 

removal of, 93 

trapping of, 92 
Pott's, 80 
recurrent, 22 

of head, 37 

of stump, 77 
roller, 14 
rubber, 81 
scissors, 18 
of Scultetus, 79 
silicate of potassium, 95 

of sodium, 95 
special, 76 
spica, 21 

of foot, 71 

of groin, ascending, 65 
descending, 66 

of shoulder, ascending, 52 
descending, 53 

of thumb, 49 
spiral, 19, 20 

of chest, 59 

of finger, 45 

reversed, 20 

of lower extremity, 74 
of penis, 76 
of upper extremity, 50 
starched, 94 

suspensorv and compressor, of 
" breast, 62 
of both breasts, 63 



Bandage of trunk, 59 

of upper extremity, 45 

Velpeau's, 55 

winder, 14 
Bandaging, 1 3 

rules for, general, 1 7 et seq. 
Barton's bandage, 32 
modified, 33 

handkerchief, 31 
Bavarian dressing, 90 
Bedsores, 272 
Bellocq's canula, 201 
Beta-naphthol, 105 
Bichloride cotton, 119 

of mercury, 103 
gauze, 115 
Binder's-board splints, 98, 300 

in compound fractures, 
360 
Bis-axillary cravat, 30 
Bladder, hemorrhage from, 262 

washing out of, 215 
Blood, transfusion of, 164 
direct, 165 
indirect, 166 
Bloodletting, 157 
Bond's splint, 332 
Bone forceps, 435 
Boric acid, 107 
Boro-salicylic lotion, 107 
Bougies, 209 

bulbous, 209 

filiform, 209 

oesophageal, 180 

rectal, 191 
Bouisson's suture, 230 
Brachial artery, ligation of, 407 
Bran bags, 301 

dressing in compound fractures, 
360 
Bread poultice, 141 
Breast, strapping of, 137 

suspensory and compressor 
bandage of, 62 
double, 63 
Bruises, 270 
Bulbous bougies, 209 
Buried suture, 223 
Burns, 271 
Button suture, 226 



CA.LCANEUM, fracture of, 354 
Cantharidal collodion, 150 
Cantharis, 150 
Capillary hemorrhage, 241 



486 



INDEX, 



Capillary hemorrhage, treatment of, 

257 
Capsicum, 149 
Carbolic acid, 104 
Carbolized gauze, 117 
Carbuncle, strapping of, 140 
Carden's amputation at knee-joint, 

473 
Carpal bones, fracture of, 334 
Carpo-metacarpal amputation of 

hand, 446 
Carpus, dislocation of, 378 
Carotid artery, common, ligation of, 
399 
external, ligation of, 401 
internal, ligation of, 402 
Cartilages, costal, fractures of, 310 

semi-lunar, dislocations of, 386 
Catgut, chromic acid, 111 
for drainage, 113 
juniper, 111 
ligatures, 111 
sutures, 111 
Catheter, elbowed, 208 
female, 212 

introduction of, 212 
flexible, 207 
introduction of, 209 
metallic, 206 
prostatic, 207 
soft rubber, 208 
tying in, 213 
Cauterization in arterial hemorrhage, 

251 
Cautery, actual, 155 
Charcoal poultice, 142 
Chest, figure-of-eight bandage of, 
anterior, 60 
posterior, 60 
spiral bandage of, 59 
strapping of, 137 
T-bandage of, double, 26 
single, 24, 25 
Children, fractures of the femur in, 
343 
leg in, 352 
Chin, four-tailed bandage of, 27 
Chloride of zinc, 106 
Chloroform, 148, 151,200 
administration of, 200 
apparatus, Clover's, 201 
Chopart's amputation of foot, 463 
Chromic acid catgut, 111 
Chronic abscess, 264 
Circular amputation, 429 
bandage. 19, 22 



Clavicle, dislocations of, 368 

of acromial end of, 369 
of sternal end of, 368 
fracture of, 314 et seq. 
in children, 318 
modified, Velpeau's dressing 

for, 319 
Sayre's dressing for, 316 
Velpeau's dressing for, 317 
Cleanliness, surgical, 102, 120 
Clinical thermometer, 189 
Closed fracture, 291 
Clove-hitch, 364 

Clover's chloroform apparatus, 201 
Cocaine, anaesthesia from, 193 
Coccyx, dislocations of, 365 

fracture of, 311 
Cold abscess, 264 

anaesthesia from, 192 
in arterial hemorrhage, 249 
compresses, 146 
Cold-water dressings, 146 
Colles's fracture, 332 
Collodion, cantharidal, 150 
Condyles of femur, fractures of, 344 
Congenital dislocations, 392 
Consecutive hemorrhage, 241 
Constitutional treatment of hemor- 
rhage, 241 
Continued suture, 223 
Contused wounds, 268 
Contusions, 270 
Comminuted fracture, 291 
Common carotid artery, ligation of, 
399 
iliac artery, ligation of, 413 
Complete dislocation, 362 

fracture, 290 
Complicated dislocation, 362, 392 

fracture, 292 
Compound bandages, 23 
dislocation, 362, 392 
- fracture, 291 

Binder's board splints in,360 
bran dressing in, 360 
dressing of, 356 
felt splints in, 360 
plaster-of-Paris dressing in, 

359 
sawdust dressing in 361 
Compresses, 132, 302 
cold, 146 

in hemorrhage, 242 
hot, 143 
Coracoid process of scapula, fracture 
of, 320 



INDEX. 



487 



Coronoid process, fracture of. 328 
Corrosive sublimate gauze, 115 
Costal cartilages, fractures of, 310 
Cotton, 130 

absorbent, 131 

bicbloride, 119 
Counter-irritation, 147 
Creolin, 107 
Crossed bandage of eye, 41 

of both eyes, 42 
Cruro-pelvic triangle, 30 
Cupping, 15S 

dry, 159 

-glass, 159 

wet, 160 
Cutting pliers, 435 
Czerny suture, 231 

DEEP incisions, 15S 
Demi-gauntlet bandage, 48 
Desault's bandage, 56 
first roller, 56 
second roller, 57 
third roller, 58 
Diastasis of sternum, 367 
Diffused suppuration, 265 
Digital compression in hemorrhage, 

241 
Dilators, tracheal, 277 
Director, tracheotomy, 276 
Dislocation or dislocations, 362 

of acromion process of scapula, 

369 
of ankle, 387 
of astragalus, 388 
of carpal bones, 378 
of carpus, 378 
of clavicle, 368 
of coccyx, 365 
complete, 362 
complicated, 362, 392 
compound, 362, 392 
congenital, 392 
dressing of. 362 
of elbow, 374 
of femur, 382 

anomalous, 334 
downward and forward, 382 
forward and upward, 384 
pubic, 384 
thyroid, 383 
of fibula, 387 
of fingers, 379 
of head of radius, 377 
of hip, 382 
of hyoid bone, 366 



Dislocation of the inferior angle of 
scapula, 369 
of jaw, 365 
of knee, 386 

of metacarpal bones, 379 
of metatarsal bones, 390 
old, 363, 390 

vertical extension in, 391 
partial, 362 
of patella, 385 
pathological, 392 
of pelvis, 367 
of phalanges of toes, 390 
of proximal phalanx of thumb, 

380 
recent, 362 
of ribs, 366 
of scapula, 369 
of semilunar cartilages, 386 
of shoulder, 370 

reduction of, 371 
simple, 362 
spontaneous, 392 
of sternum, 367 
of tarsal bones, 388, 389 
of toes, 390 
treatment of, 363 
of upper end of ulna, 377 
of vertebrae, 364 
of wrist, 377 
Dorsal dislocation of femur, 382 
Dorsalis pedis artery, ligation of, 424 
Double cyanide of mercury and zinc. 
109 
gauze, 116 
ligature, 236 
roller bandage, 16 
spring artery forceps, 252 
Drainage, catgut for, 113 
horsehair for, 113 
-tubes, 112 
glass, 113 
rubber, 112 
Dressing or dressings — 
antiseptic, 101 

improvised, 118 
moist method in, 125 
reapplication of, 125 
Bavarian, 90 
cold water, 146 
of compound fractures, 356 
of dislocations. See under each 

dislocation. 
dry sterilized, 120 
of' fractures. Pee under each 
fracture. 



488 



INDEX. 



Dressing, fixed, 82 

gauze, 115 

preparation of, 115 

hardening, 82 

moss, 117 

plaster-of- Paris, interrupted, 86 

sawdust, 117 

of septic wounds, 128 

of wounds, 266 
Dry cupping, 159 

dressings in wounds, 101 

sterilized dressings, 120 
Dupuytren's amputation at shoulder- 
joint, 454 

splint, 353 

ELASTIC ligatures, 240 
Elbow, amputations of, 448 
dislocations of, 374 
figure-of-eight bandage of, 51 
Elbowed catheter, 208 
Electrolysis, 186 
Elliptical amputation, 431 
Endoscope, 214 
Enema, glycerin, 191 
Enemata, 191 

nutritious, 191 
Epiphyseal fracture, 294 

separation, 294 
Epistaxis, 259 
Erichsen's ligature, 239 
Esmarch's bandage, 247 

elastic strap, 246 
Ether, 195 

administration of, 195 

first insensibility from, 197 

inhaler, 196 
Exploring needle, 184 

trocar, 184 
Extension, vertical, in old disloca- 
tions, 391 
External carotid artery,ligation of,40 1 

iliac artery, ligation of, 416 
Eye, Liebreich's bandage for, 78 

crossed bandage of, 41 
Eyes, crossed bandage of both, 42 

FACIAL artery, ligation of, 404 
Fascia, strains of, 275 
Faradization, 187 
Felt splints, 98, 300 

in compound fractures, 360 
Female catheter, 212 
Femoral artery, ligation of, 418 et seq. 

hernia, truss for, 205 
Femur, dislocations of, 382 



Femur, dislocations, anomalous, 384 
backward, 382 

reduction of, 382 
downward and forward, 382 

reduction of, 383 
dorsal, 382 

reduction of, 382 
below tendon, 382 
forward and upward, 384 
reduction of, 384 
iliac, 382 
ischiatic, 382 
posterior, 382 
pubic, 384 

reduction of, 384 
thyroid, 383 

reduction of, 383 
fracture of, 337 

in children, 343 
condyles of, 344 
dressing of, 337 
green-stick, 344 
lower end of, 344 
shaft of, 340 
upper extremity of, 337 
Fermenting poultice, 142 
Fibula, dislocations of, 387 
fracture of, 352 

of lower end of, 353 
Figure-of-eight bandage, 22 

of chest, anterior, 60 

posterior, 61 
of elbow, 51 
of knee, 68 
of both knees, 69 
of leg, 75 

of neck and axilla, 54 
Filiform bougie, 209 
Fingers, amputation of, 441 et seq. 
dislocations of, 379 
spiral bandage of, 45 
Fissured fracture, 291 
Fixed dressings, 82 
Flap amputation, 429 
Flaps, periosteal in amputation, 433 
Flaxseed poultice, 141 
Flexible catheters, 207 
Fomentations, hot, 142 
Foot, American bandage of, 72 
amputations of, 460 
Chopart's, 463 
Hancock's, 467 
Hey's, 463 
Lisfranc's, 461 
Mikulicz', 468. 
Tripier's, 467 



INDEX. 



489 



Foot, bandage of, not covering heel, 73 

covering heel. 72 
-bath, mustard, 149 
fractures of bones of, 354 
spica bandage of, 71 
Forced respiration, 176 
Forceps, arten r , 436 

double spring, 252 
bone, 435 

hemostatic, 247, 276, 436 
torsion. 251 
tracheal, 278 
Forearm, amputation of. 447 
fracture of bones of, 329 
green-stick fracture of, 331 
Foreign bodies, tracheotomy for, 2S4 
Fracture or fractures, 290 

of acromion process of scapula, 

320 
anaesthetics in, 296 
of astragalus, 355 
-bed, 298 
-box, 301 

double inclined, 340 
of body of scapula, 320 
of bones of foot, 354 

of leg in children, 352 
of calcaneum, 354 
of carpal bones, 334 
of clavicle, 314 et seq. 
closed, 291 
of the coccyx, 311 
comminuted, 291 
complete, 290 
complicated, 292 
compound, 291 

binder's-board splints in, 
360 

bran dressing in, 360 

continuous irrigation in, 
361 

dressing of, 356 

felt splints in, 360 

plaster-of-Faris dressing in, 
359 

sawdust dressing in, 361 
of coracoid process of scapula, 

320 
of coronoid process of ulna, 328 
of costal cartilages, 310 
direction of, 293 
dressing of, 290 et seq. 

provisional, 296 
epiphyseal, 294 
examination of, 295 
of femur, 337 



Fracture of femur in children, 343 
of libula, 352 
fissured, 291 
of forearm, 329 
green-stick, 290 
of humerus, 321 

of lower extremity, 324 

of shaft, 322 

of upper extremity, 321 
of hyoid bone, 308 
impacted, 292 
incomplete, 290 
indented, 290 
of jaw, 304, 305 
of larynx, 308 
of leg, 348 
longitudinal, 293 
of malar bone, 304 
of maxilla, lower, 305 

upper, 304 
of metacarpal bones, 335 
of metatarsal bones, 356 
multiple, 292 
of nasal bones, 302 
of neck of radius, 329 
of scapula, 320 
oblique, 293 
of olecranon, 327 
open, 291 

dressing of, 356 
partial, 290 
of patella, 345 
of pelvis, 311 
of phalanges of fingers, 335 

of toes, 356 
Pott's, 353 
punctured, 290 
of radius, 329, 331 

of head, 329 

of lower end, 331 
reduction of, 298 
repair of, 294 
of ribs, 309 
of sacrum, 311 
of scapula, 320 
setting of, 298 
of shaft of femur, 340 
simple, 291 
of skull, 313 
of sternum, 310 
of trachea, 308 
transverse, 293 
of trunk, 309 
of ulna, 327 
of upper extremity, 314 
varieties of, 290 



490 



INDEX. 



Fracture of vertebrae, 312 

of zygoma, 304 
French bandage of foot, 73 

f\ ALVANO-CAUTERY, 186 
\JT Gastrostomy, sutures for, 233 
Gastrotomy, sutures for, 235 
Gauntlet bandage, 46 
Gauze, bichloride of mercury, 115 
carbolized, 117 
corrosive sublimate, 115 
double cyanide of mercury and 

zinc, 116 
dressings, 115 

preparation of, 115 
iodoform, 116 
Gely's suture, 229 
Gibson's bandage, 34 
Glass drainage-tube, 113 
Glover's suture, 223 
Glue and oxide of zinc bandage, 96 
Gluteal artery, ligation of, 417 
Golding-Bird's tracheal dilator, 277 
Granny knot, 22 1 
Green -stick fracture, 290 

of bones of forearm, 331 
Gritti's amputation at knee-joint, 

474 
Groin, spica bandage of, ascending, 
65 
descending, 66 
double, 67 
T-bandage of, 24, 25 
Gum and chalk bandage, 95 
Gunshot wounds, 269 
Guthrie's amputation at hip-joint, 

479 
Gutta-pecha splints, 300 

HEMOSTATIC forceps, 247, 276, 
436 
Hancock's amputation of foot, 467 
Hand, amputation of, 441 

carpo-metacarpal, 446 
Hands, cleansing of, 120 

removal of plaster-of- Paris from, 
93 
Handkerchief bandages, 28 

Barton's, 31 
Hardening dressings, 82 
Hare-lip suture, 224 
Hatter's felt splints, 98 
Head, bandages of, 32 
four-tailed, 27 
oblique, 44 
recurrent, 37 



Head and neck bandage, 40 

V-bandage of, 37 
Hemorrhage, arterial, 241 

cauterization in, 251 

cold in, 249 

control of, permanent, 249 

temporary, 241 
hot water in, 249 
ligation in, 252 
position in, 249 
pressure in, 250 
torsion in, 251 
styptics in, 250 
from bladder, 262 
capillary, 241 

treatment of, 257 
compresses in, 242 
consecutive, 241 
deep suture in. 253 
digital compression in, 241 
Esmarch's elastic strap in, 246 
intermediary, 241 
parenchymatous, treatment of, 

257 
primary, 241 
from rectum, 262 
secondary, 241 

treatment of, 257 
Spanish windlass in, 244 
treatment of, 241 

constitutional, 241 
local, 241 
from urethra, 261 
venous, 241 

treatment of, 256 
Hernia, femoral, truss for 205 
inguinal, truss for,204 
irreducible, truss for. 206 
umbilical, truss for, 205 
Hey's amputation of foot, 463 
Hip-joint, amputations at, 477 et seq. 

Guthrie's, 479 
Hip, dislocations of, 382. See Femur. 
Hoey's clamp, 245 
Hood's truss, 204 
Horsehair for drainage, 113 
Hot compresses, 143 
fomentations, 142 
water, 147 

in arterial hemorrhage, 249 
Howard's method of artificial respi- 
ration, 171 
Humerus, dislocation of, subclavicu- 
lar, 370 
subcoracoid, 370 
subglenoid, 370 



INDEX 



491 



Humerus, dislocation of, subspinous, 
371 
fracture of, 321 

of lower extremitv of. 324 
of shaft of, 322 
of upper extremitv of, 321 
Hydrogen peroxide, 106 
Hypodermic syringe, 183 

injections, 182 
Hvoid bone, dislocation of, 366 
fracture of, 308 

ICE-BAG, 147 
Iliac artery, common, ligation of, 
413 

external, ligation of, 416 
internal, ligation of, 415 
dislocation of femur, 382 
Impacted fracture, 292 
Incised wounds, 266 
Incisions, deep, 158 
Incomplete fracture, 290 
India-rubber suture. 224 
Indented fracture, 290 
Inferior thvroid artery, ligation of. 

399 
Inguinal hernia, truss for, 204 
Injections, hypodermic, 1 82 
intra-venous. of milk, 169 

of saline solution, 168 
rectal. 191 
urethral. 216 
Innominate artery, ligation of, 395 
Instruments for amputation, 433 

sterilizing of, 121 
Internal carotid artery, ligation of, 
402 
iliac artery, ligation of, 415 
pudic artery, ligation of, 417 
Intermediary hemorrhage, 241 
Interosseous artery, ligation, of, 413 
Interrupted suture, 222 
Intestinal anastomosis, sutures for, 

232 
Intra-venous injection of milk, 169 
of saline solution, 168 
Intubation of larvnx, 286 
-tube. 286 

extractor, 287 
Iodoform, 105 
gauze, 116 
Irreducible hernia, truss for, 206 
Irrigating apparatus, 123 
Irrigation, 143 

continuous, 144 

in compound fractures, 361 



Irrigation, mediate. 145 
Ischiatic dislocation of femur, 382 
Isinglass plaster, 135 
Issue pea, 153 
Issues, 152 

JACKET, plaster-of Paris, applica- 
tion of, 86 
Jaw, bandage of angle of, oblique, 36 
dislocations of, 365 
lower, fracture of, 305 
splint for, 307 
upper, fracture of, 304 
Jobert's suture, 231 
Joints, strapping of, 139 
Jugular vein, external, bleeding 

from, 163 
Juniper catgut, 111 
Junk bags, 301 
Jury-mast, application of. 89 
Jute, 131 

KXEE, figure-of-eight bandage of, 
68 
of both, 69 
-joint, amputations at, 472 
Carden's, 473 
Gritti's, 474 
dislocations of, 386 
Knives, amputating, 433, 434 
Knot, granny, 221 
reef or flat, 219 
Staffordshire, 221 
surgeon's, 220 
Kreolin, 107 

LACERATED wounds, 267 
Larrey's amputation at the 
shoulder-joint, 453 
Laryngotomy, 284 
Laryngo-tracheotomy, 285 
Larvnx, fractures of, 308 

'intubation of, 286 
Leather splints, 97, 300 
Leech, mechanical, 162 
Leeching, 160 
Lembert's suture, 228 
Leg, amputation of, 468 et seq. 
Sedillofs, 472 
figure-of-eight bandage of, 75 
fracture of, 348 

in children, 352 
Liebreich's bandage, 78 
Ligation of abdominal aorta, 413 
of anterior tibial artery, 422 
in arterial hemorrhage, 252 



492 



INDEX. 



Ligation of arteries, 393 et seq. 
of axillary artery, 405 
of brachial artery, 407 
of common carotid artery, 399 

iliac artery, 413 
of dorsalis pedis artery, 424 
of external carotid artery, 401 

iliac artery, 416 
of facial artery, 404 
of femoral artery, 418 
of gluteal artery, 417 
of inferior thyroid artery, 399 
of innominate artery, 395 
of interosseous artery, 413 
of internal carotid artery, 402 
iliac artery, 415 
pudic artery, 417 
of lingual artery, 403 
of occipital artery, 404 
of popliteal artery, 421 
of posterior tibial artery, 424 
of radial artery, 409 
of sciatic artery, 417 
of subclavian artery, 396 
of superior thyroid artery, 403 
of temporal artery, 404 
of ulnar artery, 411 
of vertebral artery, 398 
of wounded arteries, 258 

Ligature or ligatures, 437 
catgut, 111 
double, 236 
elastic, 240 
Erichsen's, 239 
quadruple, 237 
securing of, 219 
single, 235 
subcutaneous, 237 
for vascular growths, 235 

Lingual artery, ligation of, 403 

Lint, 129 

Lisfranc's amputation of foot, 461 
at shoulder-joint, 455 

Lister's aorta compressor, 245 

Local anaesthesia, 192 

Longitudinal fracture, 293 

Lower extremity, bandages of, 65 
spiral reversed, 74 

Luxations. See Dislocations. 

MACKINTOSH, 114 
Malar bone, fracture of, 304 
Marshall Hall's method of artificial 

respiration, 175 
Massage, 188 

Maxilla, lower, fracture of, 305 
upper, fracture of, 304 



Mechanical leech, 162 

Medio-tarsal amputation, Chopart's, 

463 
Mercier's catheter, 208 
Mercury bichloride, 103 
Metacarpal bones, amputation of, 445 
dislocations of, 379 
fracture of, 335 
Metallic catheters, 206 
Metatarsal bones, amputation of, 459 
dislocation of, 390 
fractures of, 356 
Mikulicz, amputation of foot, 468 
Milk, intra-venous injection of, 169 
Minor surgery, 99 
Moist dressings in wounds, 102 
Moss dressing, 117 
Motion, passive, 188 
Moulded plaster-of- Paris splints, 91 
Mouth -gag, 286 

-to-mouth inflation, 170 
Moxa, 153 

Multiple fracture, 292 
Muscles, strains of, 275 
Muslin, oiled, 131 
Mustard, 148 

foot-bath, 149 

papers, 149 

plaster, 148 

YTASAL bones, fracture of, 302 

_Ll Neck, bandages of, 32 

Needle or needles, acupuncture, 152 

aneurism, 394 

exploring, 184 

-holder, 219 

mounted, 218 

seton, 154 

surgical, 218 
Nitrate of silver, 151 
Nitrous oxide gas, 194 
Nose, T-bandage of, double, 26 
Nutritious enemata, 191 

OAKUM, 130 
poultice, 142 
Oblique bandage, 19 
Oblique bandage of angle of jaw, 36 
of head, 44 
fracture, 293 
Occipital artery, ligation of, 404 
Oceipito-facial bandage, 43 
Oesophageal bougie, 180 
Oiled muslin, 131 

silk, 131 
Old dislocation, 363, 390 
Olecranon, fractures of, 327 



INDEX. 



493 



Open fracture. 291 

dressing of. 356 
Operation, aseptic, details of, 122 

preparation for. 120 
of patient for, 121 
Oval amputation, 431 

PAPER, paraffin, 132 
parchment, 114, 132 
splints. 300 
waxed. 132 
Paquelin's tkermo-cautery, 156 
Paraffin bandage, 96 

paper, 132 
Parchment paper, 114, 132 
Parenchymatous hemorrhage, treat- 
ment of. 257 
Partial dislocation, 362 

fracture, 290 
Passive motion, 188 
Pasteboard splints. 9S 
Patella, dislocations of, 385 

fracture of. 345 
Pathological dislocations, 392 
Pelvis, dislocation of, 367 

fractures of, 311 
Penis, spiral reversed bandage of. 76 
Periosteal fl?ps in amputation, 433 
Peri osteotome, 435 
Permanganate of potassium, 108 
Peroxide of hydrogen, 106 
Petit's tourniquet, 243 
Phalansres of fingers, dislocation of, 
379 
fractures of. 335 
of toes, dislocations of, 390 
fractures of, 356 
PirogofFs amputation at ankle-joint, 

465 
Plaster or plasters. 134 
adhesive, 134 
isinglass. 135 
mustard, 148 
resin, 134 

rubber adhesive, 134 
soap, 135 
spice, 149 
Plaster-of- Paris bandage, 83 

application of, 84 
preparation of, 84 
removal of. 93 
saw for, 93 
shears for, 94 
trapping of, 92 
dressing in compound frac- 
tures, 359 



Plaster-of-Paris bandage in fracture 
of femur, 339 
interrupted, 86 
jacket, application of, 86 
suspensory apparatus 
for, 87 
removal of. from hands, 93 
splints, 300 

moulded, 91 
Plate suture, 226 
Poisoned wounds, 269 
Popliteal artery, ligation of, 421 
Porous felt splints, 98 
Porte-moxa, 153 

Position in arterial hemorrhage, 249 
Posterior tibial arterv, ligation of, 

424 
Potassium permanganate, 108 
Pott's bandage, 80 

fracture, 353 
Poultice or poultices, 140 
antiseptic, 142 
bread, 141 
charcoal, 142 
fermenting. 142 
flaxseed, 141 
oakum, 142 
Powder-burns, 270 
Pressure in arterial hemorrhage, 

250 
Primarv hemorrhage. 241 

roller, 301 
Prostatic catheters, 207 
Protective. 113 

Provisional dressings of fracture. 296 
Pubic dislocation of femur. 384 
Pudic arterv, internal, ligation of, 

417 
Puncturation, 158 
Punctured fracture, 290 

wounds, 268 
Pyoktanin, 108 

QUADRUPLE ligature, 237 
Quilled suture, 225 
Quilt suture, 224 

RACK for fractures. 302 
Radial arterv. ligation of. 409 
Radius, dislocation of head of. 377 
fracture of, 329 
head of, 329 
lower end of, 331 
neck of, 329 
Rapid respiration, anaesthesia from, 
193 



22 



494 



INDEX. 



Kaw-hide splints, 97 
Eecent dislocations, 362 
Eectal bougies, 191 
injections, 191 
tube, 190 
Bectum, hemorrhage from, 262 
Recurrent bandage, 22 
of head, 37 
of stump, 77 
Eeduction of dislocations, 363 

of fractures, 298 
Eeef knot, 219 
Eesin plaster, 134 
Eespiration, artificial, 170 

direct method of, 171 
Howard's method, 171 
Marshall Hall's method of, 

175 
Sylvester's method of, 174 
forced, 176 
Eetractors, 133, 437 
three-tailed, 133 
two-tailed, 133 
Ehigolene, anaesthesia from, 192 
Eibs, dislocations of, 366 

fractures of, 309 
Eoller bandage, 14 
double, 16 
preparation of, 15 
single, 16 
primary, 301 
Eoux's amputation at ankle-joint, 

467 
Rubber adhesive plaster, 134 
bandage, 81 
drainage-tube, 112 
tissue, 114, 132 
Eubefacients, 147 

SACEUM, fractures of, 311 
Saline solution, intra-venous 
injection of, 168 
Sand bags, 301 
Saphena vein, internal, bleeding 

from, 164 
Saw, amputating, 434 

for plaster-of-Paris bandage, 93 
Sawdust dressing, 117 

in compound fractures, 361 
Sayre's dressing for fracture of 

clavicle, 316 
Scalds, 271 
Scapula, dislocations of, 369 

acromial process of, 369 
inferior angle of, 369 
fracture of, 320 



Scapula, fracture of body of, 320 

neck of, 320 
Scarification, 157 
Scarificator, 160 
Sciatic artery, ligation of, 417 
Scissors, bandage, 18 

skin-grafting, 185 
Scultetus, bandage of, 79 
Secondary hemorrhage, 241 
treatment of, 257 
sutures, 217 
Sedillot's amputation of leg, 472 
Semilunar cartilages, dislocation of, 

386 
Septic wounds, dressing of, 128 
Seton, 153 

needle, 154 
Setting of fractures, 298 
Shears for plaster-of-Paris bandage, 

94 
Shotted suture, 227 
Shoulder, dislocations of, 370 
reduction of, 371 
-joint, amputation above, 456 
amputation at, 452 et seq. 
Dupuytren's, 454 
Larrey's, 453 
Lisfranc's, 455 
Spence's, 455 
spica bandage of ascending, 52 
descending, 53 
Signorini's tourniquet, 245 
Silicate of potassium bandage, 95 

of sodium bandage, 95 
Silk, 110 

oiled, 131 
Silkworm-gut, 111 
Simple dislocation, 362 

fracture, 291 
Sinapism, 148 
Single ligature, 235 

roller bandage, 16 
Sinuses from abscesses, 265 
Skin-grafting, 185 
Skull, fractures of, 313 
Slings, 26 
Soap plaster, 135 
Soft rubber catheter, 208 
Sounds, 209 
Spanish windlass, 244 
Spence's amputation at the shoulder- 
joint, 455 
Spica bandage, 21 
of foot, 71 

of groin, ascending, 65 
descending, 66 



INDEX. 



495 



Spica bandage of groin, double, 67 
of shoulder, ascending, 52 

descending, 53 
of thumb, 49 
Spice plaster, 149 
Spiral bandage, 19, 20 
of chest, 59 
of finger, 45 
reversed bandage, 20 

of lower extremity, 74 
of penis, 76 
of upper extremity", 50 
Splints, 299 

angular, anterior, 325 

internal, 323 
binder's board, 98, 300 

in compound fractures, 
360 
Bond's, 332 
Dupuytren's, 353 
felt, 300 

in compound fractures, 360 
gutta-percha, 300 
hatter's felt, 98 
leather, 97, 300 
moulded binder's-board, 351 
paper, 300 
pasteboard, 98 
plaster of- Paris, 300 

moulded, 91 
porous felt, 98 
raw-hide, 97 
wooden, 299 
Sponges, 109 

Spontaneous dislocations, 392 
Sprain-fracture, 274 
Sprains, 273 
Staffordshire knot, 221 
Staphylococcus pyogenes albus, 100 

aureus, 100 
Starched bandage, 94 
Sterilization, chemical, in dressing of 

wounds, 101 
Sterilized dressings, dry, 120 
Sterilizing of instruments, 121 

oven, 119 
Sternum, diastasis of, 367 
dislocations of, 367 
fractures of, 310 
Stomach-pump, 180 

-tube, 178 
Strains of fascia, 275 

of muscles, 275 
Strangury, 151 
Strapping, 135 
of breast, 137 



Strapping of carbuncle, 140 

of chest, 137 

of joints, 139 

of testicle, 136 

of ulcers, 138 
Streptococcus pyogenes, 100 
Stump, recurrent bandage of, 77 
Styptics in arterial hemorrhage, 250 
Subastragaloid amputation, 464 
Subclavian artery, ligation of, 396 
Subclavicular dislocation of humerus, 

370 
Subcoracoid dislocation of humerus, 

370 
Subcutaneous ligature, 237 
Subglenoid dislocation of humerus, 

370 
Subspinous dislocation of humerus, 

371 
Sulphocarbolate of zinc, 106 
Superior thyroid artery, ligation of, 

403 
Suppuration, diffused, 265 
Surface thermometer, 189 
Surgeon's knot, 220 

and reef knot combined, 220 
Surgery, aseptic, materials used in, 
preparation of, 199 

minor, 99 
Surgical cleanliness, 102, 120 

needles, 218 
Suspensory apparatus for plaster-of- 
Paris jacket, 87 

and compressor bandage of 
breast, 62 
of both breasts, 63 
Sutures or suture, 217, 437 

of approximation, 217 

Bouisson's, 230 

buried, 223 

button, 226 

catgut, 111 

of coaptation, 217 

continued, 223 

Czerny, 231 

deep, in hemorrhage, 253 

for gastrostomy, 233 

for gastrotomy, 235 

Gely's, 229 

glover's, 223 

hare-lip, 224 

India-rubber, 224 

for intestinal anastomosis, 232 

interrupted, 222 

Jobert's, 231 

Lembert's, 228 



496 



INDEX. 



Sutures, plate, 226 

quilled, 225 

quilt, 224 

of relaxation, 217 

removal of, 228 

secondary, 217 

securing of, 219 

shotted, 227 

tongue-and-groove, 227 

twisted, 224 
Sylvester's method of artificial respi- 
ration, If 4 
Syme's amputation at ankle-joint, 

464 
Syringe, hypodermic, 183 

T -BANDAGE, 23 
of chest, double, 26 
single, 24, 25 

double, 25 

of groin, 24,25 

of nose, double, 26 

single, 23 
Tarsal bones, dislocation of, 388, 389 
Tarso-metatarsal amputations, 460 
Teale's amputation, 432 
Temporal artery, ligation of, 404 
Tenaculum, 252, 436 
Tent, 133 

Testicle, strapping of, 1 36 
Thermo-cautery, Paquelin's, 156 
Thermometer, clinical, 189 

surface, 189 
Thigh, amputation of, 475 et seq. 
Three-tailed retractors, 133 
Thumb, dislocation of proximal pha- 
lanx of, 380 

spica bandage of, 49 
Thyroid artery, inferior, ligation of, 
399 
superior, ligation of, 403 

dislocation of femur, 383 
Tibial artery, anterior, ligation of, 422 

posterior, ligation of, 424 
Tissue, rubber, 114, 152 
Toes, amputation of, 456 

dislocations of, 390 

fractures of, 356 
Tongue-and-groove suture, 227 
Torsion in arterial hemorrhage, 251 

forceps, 251 
Tourniquets, 243, 438 

abdominal, 477 

Petit's, 243 

Signorini's, 245 
Trachea, fracture of, 308 



Tracheal dilators, 277 

Golding-Bird's, 277 
Trousseau's 277 

forceps, 278 
Tracheotomy, 275 

ansesthetics in, 279 

director, 276 

for foreign bodies, 284 

position of patient in, 279 

operation of, 279 

tubes, 278 
Transfusion, arterial, 167 

of blood, 164 
direct, 165 
indirect, 165 
Trapping of plaster-of- Paris bandage, 

92 
Transverse fracture, 293 
Tripier's amputation of foot, 467 
Trocar, exploring, 184 
Trousseau's tracheal dilator, 277 
Trunk, bandages of, 59 

fractures of, 309 
Truss or trusses, 202 

application of, 203 et seq. 

for femoral hernia, 205 

Hood's, 204 

for inguinal hernia, 204 

for irreducible hernia, 206 

for umbilical hernia, 205 
Tube, rectal, 190 

tracheal, 278 
Turpentine, 148 

stupe, 148 
Twisted suture, 224 
Two-tailed retractors, 133 

ULCERS, strapping of, 138 
Ulna, dislocation of lower end of, 
377 
upper end of, 377 
fracture of, 327 

coronoid process of, 328 
olecranon process of, 327 
Ulnar artery, ligation of, 411 
Umbilical hernia, truss for, 205 
Upper extremity, bandage of, 45 
fractures of, 314 
spiral reversed bandage of, 50 
Urethra, hemorrhage from, 261 
Urethral injections, 216 
Urethroscope, 215 

V -BANDAGE of head, 39 
Vaccination, 181 
Vascular growths, ligatures for, 235 



INDEX. 



497 



Vein, jugular, bleeding from, 163 
saphena, bleeding from, 164 

Velpeau's bandage, 55 

dressing for fracture of clavicle, 
317 

Venesection, 162 

Venous hemorrhage, 241 
treatment of, 256 

Vertebra?, dislocations of, 364 
fractures of, 312 

Vertebral artery, ligation of, 398 

Vesicants, 150 

TI7A8HING out the bladder, 215 
}} Water-bed, 312 
Waxed paper, 132 
Wet cupping, 160 
Wooden splints, 299 
Wounds, aseptic, dressing of, 101 



Wounds, chemical sterilization in, 
101 

contused, 268 

dressing of, 266 

dry dressing in, 101 

gunshot, 269 

incised, 266 

lacerated, 267 

moist diessings in, 102 
modified, 102 

poisoned, 269 

punctured, 268 

septic, dressing of, 128 
Wrist, amputation at, 446 

dislocations of, 377 

ZINC, chloride of, 106 
sulpho-carbolate of, 106 
Zygoma, fracture of, 304 



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